COVID-2019 Alert

The latest information about the 2019 Novel Coronavirus, including vaccine clinics for children ages 5 years old and older.

La información más reciente sobre el nuevo Coronavirus de 2019, incluidas las clínicas de vacunación para niños de 5 años en adelante.


Andrea Kossler, MD

  • Andrea L Kossler



Work and Education

Professional Education

Georgetown University Internal Medicine Residency, Washington, DC, 2006


Mount Sinai Med Ctr/ Miami Bch, Miami Beach, FL, 2007


Bascom Palmer Eye Institute, Miami, FL, 2010


Bascom Palmer Eye Institute, Miami, FL, 2012

Board Certifications

Ophthalmology, American Board of Ophthalmology


Eyes & Vision

Conditions Treated

Neurostimulation for Ocular Surface Disease

Orbital Oncology

Thyroid Eye Disease

All Publications

Modified Gundersen Flap Using Inferior Palpebral-Bulbar Conjunctiva. Cornea Mekonnen, B., Kossler, A. L., Lin, C. C. 1800; 41 (2): 260-263


PURPOSE: The purpose of this article was to describe a modification to the traditional Gundersen flap technique that expands eligible eyes to include those with severe conjunctival scarring and to report results from a clinical case.METHODS: A 68-year-old woman with a history of herpes simplex keratitis, multiple failed penetrating keratoplasties, lagophthalmos, persistent epithelial defect, and low visual potential in the left eye presented for the evaluation of a Gundersen flap. Severe superior bulbar conjunctival scarring precluded a traditional approach. A modified Gundersen flap technique using a contiguous flap of inferior palpebral-bulbar conjunctiva extending from the inferior tarsal border to the limbus was devised and performed.RESULTS: The modified Gundersen flap technique successfully stabilized the ocular surface, obviating the need for a cosmetically disfiguring permanent tarsorrhaphy or an evisceration.CONCLUSIONS: This modified Gundersen flap technique expands the indications to eyes with severe conjunctival scarring and can be offered in eyes with previous trabeculectomies, glaucoma drainage implants, and scleral buckles, which were previously excluded from the globe-preserving option.

View details for DOI 10.1097/ICO.0000000000002823

View details for PubMedID 35037907

#PlasticsTwitter: The Use of Twitter Data s a Tool for Evaluating Public Interest in Cosmetic Surgery Procedures. Aesthetic surgery journal Cohen, S. A., Tijerina, J. D., Amarikwa, L., Men, C., Kossler, A. 1800


BACKGROUND: Plastic surgeons are increasingly turning to social media to market their services. The newly released Twitter Academic Research Product Track (TARPT) database provides free, customizable analysis of keywords that are included in tweets on the Twitter platform. The TARPT tool may provide valuable insight into public interest in cosmetic surgery procedures.OBJECTIVES: To determine TARPT's utility in tracking and predicting public interest in cosmetic surgery procedures and to examine temporal trends in tweets related to cosmetic facial and body procedures.METHODS: The TARPT tool was used to calculate total number of tweets containing keywords related to 10 facial cosmetic procedures and 7 cosmetic body procedures from 2010 to 2020. Annual volumes for respective procedures were obtained from annual statistics reports of the American Society of Plastic Surgeons (ASPS) from 2010 to 2020. Univariate linear regression was used to compare tweet volumes and procedure volumes, taking P < 0.05 as the cutoff for significance.RESULTS: Variations in tweet volume were observed. Univariate linear regression analysis demonstrated statistically significant positive correlations between tweet volumes and ASPS procedure volumes for 7 search terms: "eyelid lift", "facelift", "lip injections", "mastopexy", "butt lift", "butt implants", and "liposuction". Many procedure-related keywords were not significant, demonstrating the importance of careful selection of Twitter search terms.CONCLUSIONS: The TARPT database represents a promising novel source of information for plastic surgeons, which the potential to inform marketing and advertising decisions for emerging trends in plastic surgery interest before these patterns become apparent in surgical or clinical volumes.

View details for DOI 10.1093/asj/sjab429

View details for PubMedID 34962572

Representation of Women in Ophthalmology Subspecialty Societies over 20 Years. Ophthalmology Azad, A. D., Chandramohan, A., Li, A. S., Rosenblatt, T. R., Reeves, M. R., Pasricha, M. V., Ludwig, C. A., Nguyen, A., Winges, K. M., Wang, S. Y., Pan, C. K., Moss, H. E., Do, D. V., Fountain, T. R., Kossler, A. L. 1800


The representation of women has increased over the last 20 years among ophthalmology subspecialty society new membership, award winners, and executive committee membership; however, proportional representation is still lacking at most benchmarks.

View details for DOI 10.1016/j.ophtha.2021.12.011

View details for PubMedID 34958831

Infusion Center Guidelines for Teprotumumab Infusions: Informed Consent, Safety, and Management of Side Effects. Journal of infusion nursing : the official publication of the Infusion Nurses Society Kang, J., Lechuga, M., Braun, J., Kossler, A., Douglas, R., Cockerham, K. 2021; 44 (6): 331-338


Teprotumumab was the first and only medication approved by the US Food and Drug Administration for the treatment of thyroid eye disease in January 2020. Thyroid eye disease is a complex autoimmune inflammatory disease that can be sight-threatening, debilitating, and disfiguring to affected patients. Although biologic therapies are a preferred treatment option for many complex immunologic and oncologic conditions, their use in ophthalmology and endocrinology may be more novel. The goals of this article are to introduce this new therapeutic option; discuss its mechanism of action, indications for use, administration protocol, infusion precautions, and informed consent; and review common side effects and management.

View details for DOI 10.1097/NAN.0000000000000446

View details for PubMedID 34753152

Corneal Neurotization via Dual Nerve Autografting. Ophthalmic plastic and reconstructive surgery Charlson, E. S., Pepper, J. P., Kossler, A. L. 2021


Corneal neurotization is a fast-evolving surgical procedure for sensory reinnervation in neurotrophic keratopathy. After neurotization, prior reports document return of corneal sensation on average 8 months after surgery with 38mm of sensation gain measured via cochet bonnet esthesiometer testing. Here, the authors describe a dual nerve grafting approach via simultaneous parallel sural nerve grafts from both the supratrochelar and supraorbital nerves to the affected contralateral cornea with return of sensation by postoperative week 11.

View details for DOI 10.1097/IOP.0000000000002064

View details for PubMedID 34652308

Early efficacy of teprotumumab for the treatment of dysthyroid optic neuropathy: A multicenter study. American journal of ophthalmology case reports Sears, C. M., Wang, Y., Bailey, L. A., Turbin, R., Subramanian, P. S., Douglas, R., Cockerham, K., Kossler, A. L. 2021; 23: 101111


Purpose: To study post-interventional findings in patients with dysthyroid optic neuropathy (DON) treated with teprotumumab.Observations: In this multicenter observational Case series, patients with DON were treated with teprotumumab, an insulin-like growth factor I receptor inhibitor (10 mg/kg for the first infusion then 20 mg/kg for subsequent infusions, every three weeks for a total 8 infusions). This study included patients with acute and chronic thyroid eye disease (TED) with DON who had failed conventional therapies and were not candidates for surgical decompression. Data collected included best corrected visual acuity (BCVA), color vision, RAPD when present, and orbital CT or MRI. Proptosis, clinical activity score (CAS), Gorman diplopia score (GDS), and Humphrey visual fields (HVF) were also evaluated.Ten patients (6 women, 4 men) with an average age 64 years old were included in this study. Mean follow up after completion of infusions was 15 weeks. Baseline visual acuity (VA) impairment ranged from hand motion (HM) to 20/25 in affected eyes. All patients had pre-treatment orbital CT or MRI that confirmed orbital apex compression. Seventy percent of patients had objective improvement in DON after 2 infusions of teprotumumab measured as significant improvement in visual acuity, resolution of RAPD, or both. After completion of treatment, affected eyes had a mean BCVA improvement of 0.87 logMAR (p=0.0207), proptosis reduction of 4.7 mm (p<0.00001), CAS improvement of 5.25 points (p<0.00001), and GDS improvement of 0.75 points (p=0.160). All 6 patients who presented with an RAPD had resolution or improvement of RAPD. All 7 patients who presented with color vision deficits had normalization or improvement of color vision.Conclusions and Importance: Teprotumumab infusions resulted in medical decompression and objective resolution or improvement of dysthyroid optic neuropathy. Most patients had rapid improvement of visual acuity and reversal of RAPD. Post-infusion imaging demonstrated reduction in extraocular muscle size that correlated with improvement in visual dysfunction. However, patients who presented with longstanding severe visual loss had limited improvement. There was no recurrence of DON after completion of teprotumumab in our cohort.

View details for DOI 10.1016/j.ajoc.2021.101111

View details for PubMedID 34113737

Ophthalmic artery occlusion following n-butyl cyanoacrylate embolization of an orbital arteriovenous malformation. Orbit (Amsterdam, Netherlands) Shoji, M. K., Tran, A. Q., Lee, W. W., Dubovy, S. R., Kossler, A. L. 2021: 1-7


A 33-year-old pregnant woman presented with six months of right-sided proptosis. Neuroimaging revealed a right orbital arteriovenous malformation arising from the second segment of the ophthalmic artery. As she was 9weeks pregnant, the decision was made to monitor her closely. Over the following six months, her proptosis progressed, accompanied by decreased visual acuity, afferent pupillary defect, and red desaturation concerning for compressive optic neuropathy. After planned c-section, she underwent embolization with n-butyl cyanoacrylate. Upon awakening after embolization, she had no light perception vision from her right eye and was found to have ophthalmic artery obstruction. She ultimately developed a blind painful right eye and underwent enucleation with histopathology demonstrating glue in the central retinal artery, posterior ciliary arteries, and choroid. This case highlights ophthalmic artery occlusion as a rare complication of orbital arteriovenous malformation embolization and demonstrates correlating histopathological findings, which have not previously been reported.

View details for DOI 10.1080/01676830.2021.1955937

View details for PubMedID 34365893

Teprotumumab for the treatment of chronic thyroid eye disease. Eye (London, England) Ugradar, S., Kang, J., Kossler, A. L., Zimmerman, E., Braun, J., Harrison, A. R., Bose, S., Cockerham, K., Douglas, R. S. 2021


BACKGROUND: Teprotumumab, a novel IGF-1R antibody was recently shown to significantly reduce the signs of active Thyroid eye disease (TED). The current study reviews its efficacy in chronic TED.METHODS: In this retrospective review, consecutive patients with chronic stable TED (>2 years), who had received 3 infusions of teprotumumab were included. All patients had measurements of proptosis, and calculation of the CAS and diplopia scores before and after therapy. Five-point strabismus scores were also calculated. Patients who had imaging within 4 months prior to therapy and 6 weeks post therapy underwent orbital 3D volumetric analysis.RESULTS: Thirty-one patients met the inclusion criteria. The mean (SD) duration of TED was 81 months (56) and the mean (SD) number of infusions received by each patient was 7 (2). Mean (SD) reduction in proptosis for each study orbit was 3.5mm (0.4) and 3mm (0.3) for the fellow orbit. The CAS response was 90% for the study orbit and 87% for the fellow orbit. Of the 15 patients who had diplopia at baseline, 67% had a clinically significant response, while 47% had complete resolution following treatment. Following teprotumumab, mean (SD) reduction of muscle tissue was 2011mm3 (1847) in the study orbit and 1620mm3 (1759) in the fellow orbit. The mean (SD) reduction of fat volume was 2101 mm3 (1681) in the study orbit and 1370mm3 (1181) in the fellow orbit.CONCLUSION: Teprotumumab significantly reduces proptosis, inflammation, diplopia, strabismus and orbital soft tissue volume in patients with chronic TED.

View details for DOI 10.1038/s41433-021-01593-z

View details for PubMedID 34244669

Thyroid Eye Disease: Navigating the New Treatment Landscape. Journal of the Endocrine Society Dosiou, C., Kossler, A. L. 2021; 5 (5): bvab034


Thyroid eye disease (TED) is a complex inflammatory disease that can have a long clinical course with sight-threatening and debilitating ocular sequelae. Until recently, there were limited therapeutic options available. In the last decade we have gained a deeper understanding of the underlying pathophysiology, which has led to the development of novel effective targeted therapies. This article discusses the challenges encountered in the clinical evaluation and treatment of TED patients, with the goal to empower endocrinologists and ophthalmologists to work together to provide effective multidisciplinary care. We will review recommendations of past clinical guidelines around evaluation and management of TED patients, discuss the randomized controlled trials of new biologic therapies, and explore how to navigate the emerging therapeutic landscape.

View details for DOI 10.1210/jendso/bvab034

View details for PubMedID 33948524

New Indicator of Children's Excessive Electronic Screen Use and Factors in Meibomian Gland Atrophy. American journal of ophthalmology Cremers, S. L., Khan, A. R., Ahn, J., Cremers, L., Weber, J., Kossler, A. L., Pigotti, C., Martinez, A. 2021


PURPOSE: To evaluate the association of children's daily-electronic-screen-use with severe meibomian-gland-atrophy (MGA).DESIGN: Retrospective cross-sectional study METHODS: Children (6-17years) presenting at clinical practice December 2016-2017 were evaluated for grade 2 MGA versus age-matched-controls with insignificant atrophy (

View details for DOI 10.1016/j.ajo.2021.03.035

View details for PubMedID 33857506

Multi-compartment skull base orbital cavernous venous malformation: A rare presentation of a common orbital mass. American journal of ophthalmology case reports Azad, A. D., Sears, C. M., Hwang, P. H., Mohyeldin, A., Fernandez-Miranda, J., Kossler, A. L. 2021; 21: 101020


Purpose: We present a unique case of an orbital intraconal cavernous venous malformation that extended along the trigeminal nerve to the pterygopalatine and middle cranial fossa. Our aim is to describe an atypical presentation of this common orbital vascular mass.Observations: A 57-year-old female presented with right eye proptosis. Orbital magnetic resonance imaging demonstrated a lobulated contrast-enhancing mass involving the right intraconal orbital space, pterygopalatine fossa, and right middle cranial fossa, radiographically presumed to be a schwannoma. Intraoperative and histopathologic evaluation confirmed a cavernous venous malformation that extended along the trigeminal nerve. The mass, including its attachments to the cranial nerves and dura, was successfully removed via a combined transorbital and endoscopic endonasal approach. The patient recovered well with 20/20 vision, full extraocular movements, and resolution of proptosis.Conclusions: This a rare presentation of an orbital cavernous venous malformation not previously described. Cavernous venous malformations typically present as ovoid well-circumscribed lesions; however, they can also extend outside the orbit along the path of cranial nerves, as was observed in this case. These types of lesions should be included in the differential diagnosis of masses arising from or extending along cranial nerves, even when involving the orbit.

View details for DOI 10.1016/j.ajoc.2021.101020

View details for PubMedID 33598587

A deep learning approach to identify blepharoptosis by convolutional neural networks. International journal of medical informatics Hung, J. Y., Perera, C. n., Chen, K. W., Myung, D. n., Chiu, H. K., Fuh, C. S., Hsu, C. R., Liao, S. L., Kossler, A. L. 2021; 148: 104402


Blepharoptosis is a known cause of reversible vision loss. Accurate assessment can be difficult, especially amongst non-specialists. Existing automated techniques disrupt clinical workflow by requiring user input, or placement of reference markers. Neural networks are known to be effective in image classification tasks. We aim to develop an algorithm that can accurately identify blepharoptosis from a clinical photo.A total of 500 clinical photographs from patients with and without blepharoptosis were sourced from a tertiary ophthalmic center in Taiwan. Images were labeled by two oculoplastic surgeons, with an independent third oculoplastic surgeon to adjudicate disagreements. These images were used to train a series of convolutional neural networks (CNNs) to ascertain the best CNN architecture for this particular task.Of the models that trained on the dataset, most were able to identify ptosis images with reasonable accuracy. We found the best performing model to use the DenseNet121 architecture without pre-training which achieved a sensitivity of 90.1 % with a specificity of 82.4 %, compared to the worst performing model which was used a Resnet34 architecture with pre-training, achieving a sensitivity of 74.1 %, and specificity of 63.6 %. Models with and without pre-training performed similarly (mean accuracy 82.6 % vs. 85.8 % respectively, p = 0.06), though models with pre-training took less time to train (1-minute vs. 16 min, p < 0.01).We report the use of AI to accurately diagnose blepharoptosis from a clinical photograph with no external reference markers or user input requirement. Most current-generation CNN architectures performed reasonably on this task, with the DenseNet121, and Resnet18 architectures without pre-training performing best in our dataset.

View details for DOI 10.1016/j.ijmedinf.2021.104402

View details for PubMedID 33609928

Genome Sequencing and Apoptotic Markers to Assess Treatment Response of Lacrimal Gland Adenoid Cystic Carcinoma to Intra-Arterial Cytoreductive Chemotherapy. Ophthalmic plastic and reconstructive surgery Yu, M. D., Men, C. J., Do, H., Colevas, A. D., Lin, J. H., Egbert, P. R., Tse, D. T., Kossler, A. L. 2021


Adenoid cystic carcinoma of the lacrimal gland is an aggressive, malignant epithelial neoplasm. We report the case of a 30-year-old male with lacrimal gland adenoid cystic carcinoma treated with neoadjuvant intra-arterial chemotherapy through the internal carotid artery, followed by orbital exenteration and chemoradiation. Treatment response was evaluated using a novel combination of pre- and posttreatment genome sequencing coupled with immunohistochemical evaluation, which showed diffuse tumor apoptosis. A posttreatment decrease in variant allele frequency of the NOTCH1 mutation, and robust tumor cytoreduction on imaging, supports exploration of NOTCH1 analysis as a potential marker of cisplatin sensitivity. The use of genome sequencing and immunohistochemical evaluation could provide a more targeted therapeutic assessment of neoadjuvant intra-arterial chemotherapy in the management of lacrimal gland adenoid cystic carcinoma.

View details for DOI 10.1097/IOP.0000000000002079

View details for PubMedID 34798653

Ocular, Orbital, and Adnexal Toxicity With High-dose Volumetric Modulated Arc Radiation Therapy For Orbital Malignancies. Ophthalmic plastic and reconstructive surgery Garcia, G. A., Charlson, E. S., Kolseth, C., Kim, N., Kossler, A. L. 2021


Conventional modalities of external-beam radiation therapy (EBRT) are associated with high incidences of severe vision-threatening ocular and orbital toxicities when used to treat orbital malignancies. We investigate toxicities associated with high-dose volumetric modulated arc therapy (VMAT), a commonly used contemporary treatment modality for these tumors.Retrospective analysis of malignant orbital tumors managed with adjuvant high-dose VMAT preceded by globe-salvaging surgical therapy (GST) or exenteration. Dosimetric quantitation of target volumes and critical structures was performed. Incidence and severity of ocular, orbital, and adnexal toxicities were evaluated and assessed with regard to conventional EBRT toxicities for orbital malignancies described in the literature.Eighty-four subjects (mean age = 65.9 9.7 years) were included (N = 48 and N = 36 in GST and exenteration subgroups, respectively). Mean dose was 64.8 2.1 Gy to the planning target volume. Dosing to critical structures typically did not surpass known tissue tolerance limits. Median follow up was 18.3 months. Visual acuity in the GST subgroup was not significantly different after VMAT (0.25 0.06) compared with baseline (0.23 0.02; P = 0.302). Whereas severe toxicities reported by major systematic analyses in the literature with older EBRT modalities were relatively common-for example, retinopathy (16-40%), optic neuropathy (16%), and corneal perforation (13%)-toxicities with VMAT were typically mild and less common. The most common toxicities with VMAT were mild dry eye (81.3%; 39/48), cataract (21.1%; 8/38 phakic eyes), and periocular dermatitis (15.5%; 13/84). Vision-threatening toxicities, including severe corneal pathologies, retinopathy, or optic neuropathy, were rare. There were no contralateral ocular or adnexal toxicities.High-dose VMAT for orbital malignancies demonstrated low incidence and severity of eye-related toxicity, in contradistinction to adverse events reported from conventional forms of radiotherapy.

View details for DOI 10.1097/IOP.0000000000002001

View details for PubMedID 34284423

Stimulating Tear Production: Spotlight on Neurostimulation. Clinical ophthalmology (Auckland, N.Z.) Yu, M. D., Park, J. K., Kossler, A. L. 2021; 15: 4219-4226


Dry eye disease (DED) affects up to one-third of the global population. Traditional therapies, including topical lubricants, have been employed with variable success in the treatment of DED. Recently, neurostimulation of the lacrimal functional unit (LFU) has emerged as a promising alternative therapy for DED. In this review, we describe the neuroanatomical and pathophysiological considerations of DED and the LFU that make neurostimulation a viable therapeutic alternative. We further detail the various neurostimulatory approaches taken thus far-from implanted stimulators to external devices to chemical neurostimulation. Existing studies reveal the strengths of the neurostimulatory approach in increasing tear volume and improving dry eye symptoms, but further studies are needed to elucidate its true potential in treatment of DED.

View details for DOI 10.2147/OPTH.S284622

View details for PubMedID 34707341

Perioperative management of antithrombotic medications: An investigation into current U. S. ophthalmologic recommendations Journal of Current Ophthalmology Garcia, G. A., Bair, H., Kossler, A. L. 2021; 33 (2): 182-188

View details for DOI 10.4103/2452-2325.303201

Updates on the understanding and management of thyroid eye disease. Therapeutic advances in ophthalmology Men, C. J., Kossler, A. L., Wester, S. T. 2021; 13: 25158414211027760


Thyroid eye disease (TED) is a complex disease associated with myriad clinical presentations, including facial disfigurement, vision loss, and decreased quality of life. Traditionally, steroid therapy and/or radiation therapy were commonly used in the treatment of active TED. While these therapies can help reduce inflammation, they often do not have a sustainable, significant long-term effect on disease outcomes, including proptosis and diplopia. Recent advances in our understanding of the pathophysiology of TED have shifted the focus of treatment toward targeted biologic therapies. Biologics have the advantage of precise immune modulation, which can have better safety profiles and greater efficacy compared to traditional approaches. For instance, the insulin-like growth factor-1 receptor (IGF-1R) has been found to be upregulated in TED patients and to colocalize with the thyroid-stimulating hormone receptor (TSHR), forming a signaling complex. Teprotumumab is an antibody targeted against IGF-1R. By inhibiting the IGF-1R/TSHR signaling pathway, teprotumumab may reduce the production of proinflammatory cytokines, hyaluronan secretion, and orbital fibroblast activation in patients with TED. Due to promising phase II and III clinical trial results, teprotumumab has become the first biologic US Food and Drug Administration (FDA)-approved for the treatment of TED. In addition, there are currently ongoing studies looking at the use of antibodies targeting the neonatal Fc receptor (FcRn) in various autoimmune diseases, including TED. FcRn functions to transport immunoglobulin G (IgG) and prevent their lysosomal degradation. By blocking the recycling of IgG, this approach may dampen the body's immune response, in particular the pathogenic IgG implicated in some autoimmune diseases. Advances in our understanding of the pathophysiology of TED, therefore, are leading to more targeted therapeutic options, and we are entering an exciting new phase in the management of TED. This review will cover recent insights into the understanding of TED pathophysiology and novel treatment options as well as ongoing studies of new potential treatment options for TED.

View details for DOI 10.1177/25158414211027760

View details for PubMedID 34263138

Microphthalmia and orbital cysts in DiGeorge syndrome. Journal of AAPOS : the official publication of the American Association for Pediatric Ophthalmology and Strabismus Chandramohan, A., Sears, C. M., Huang, L. C., Beres, S., Fredrick, D., Kossler, A. L. 2021

View details for DOI 10.1016/j.jaapos.2021.06.001

View details for PubMedID 34597781

Corneal Neurotization and Novel Medical Therapies for Neurotrophic Keratopathy CURRENT OPHTHALMOLOGY REPORTS Rosenblatt, T. R., Sears, C. M., Park, J., Kossler, A. 2020; 8 (4): 252-266
Cannibalistic bilateral orbital trauma. American journal of ophthalmology case reports Rosenblatt, T. R., Garcia, G. A., Johnson, T. E., Kossler, A. L. 2020; 20: 100983


Purpose: To describe the details of a unique case of cannibalistic orbital trauma and the oculoplastic reconstruction approach.Observations: A 65-year-old homeless man survived a disfiguring cannibalistic facial and bilateral orbital injury that included bilateral loss of all adnexal structures, partial exenteration of the left orbit, and severe damage to the right globe and anterior orbital structures. The patient's extensive facial and orbital tissue damage required emergent surgery, which included left exenteration and right eyelid reconstruction.Conclusions: This is the first report of cannibalistic evisceration in a live victim who survived the attack, posing a unique reconstructive challenge. Bilateral globe removal was avoided to provide time for the patient's emotional recovery. Although this was an exceptional surgical scenario, traditional oculoplastic principles remained crucial to achieving a successful outcome. The patient survived and was pleased with his surgical outcome, refusing further reconstruction or prosthesis fitting.

View details for DOI 10.1016/j.ajoc.2020.100983

View details for PubMedID 33163692

Outcomes of corneal neurotisation using processed nerve allografts: a multicentre case series. The British journal of ophthalmology Sweeney, A. R., Wang, M., Weller, C. L., Burkat, C., Kossler, A. L., Lee, B. W., Yen, M. T. 2020


BACKGROUND: Corneal neurotisation is a rapidly evolving procedure treating neurotrophic keratopathy. The variety of surgical techniques used and corresponding outcomes after corneal neurotisation are not well understood. This study describes the techniques and outcomes in the largest case series of corneal neurotisation using processed nerve allografts to date.METHODS: This is a retrospective case series of patients who underwent corneal neurotisation with human cadaveric processed nerve allografts. All patients had preoperative and postoperative description of best corrected visual acuity and measurement of corneal sensation. Comparative studies after stratification of techniques were performed.RESULTS: A total of 17 patients were identified. The cause of corneal anaesthesia was prior infection in eight cases, trigeminal nerve palsy in eight cases and ocular trauma in one case. There were no intraoperative or postoperative complications. Following neurotisation surgery, the time to first gain of corneal sensation and maximal gain of sensation occurred at a mean of 3.7 months (range 1-8 months) and 6.6 months (range 3-15 months), respectively. The mean preoperative and postoperative corneal sensation as measured by Cochet-Bonnet aesthesiometry was 0.36cm (range 0-3.2cm) and 4.42cm (range 0-6cm), respectively (p<0.01). Visual acuity was unchanged after neurotisation. There were no statistical differences in outcomes based on end-to-end versus end-to-side coaptations, donor nerve selection or laterality of donor nerve.CONCLUSION: Corneal neurotisation with processed nerve allografts is a safe and effective procedure. This study provides further evidence for the use of processed nerve allografts for corneal neurotisation.

View details for DOI 10.1136/bjophthalmol-2020-317361

View details for PubMedID 33199302

Bilateral Atypical Eyelid Lesions in a 50-Year-Old Woman. JAMA ophthalmology Azad, A. D., Charlson, E. S., Kossler, A. L. 2020

View details for DOI 10.1001/jamaophthalmol.2020.2090

View details for PubMedID 33057579

Pseudoprogression of Metastatic Melanoma to the Orbit With Pembrolizumab. Ophthalmic plastic and reconstructive surgery Garcia, G. A., Topping, K. L., Mruthyunjaya, P. n., Kossler, A. L. ; 36 (2): e36e40


The management of metastatic melanoma to the orbit may involve a variety of therapeutic modalities including external-beam radiation, chemotherapy, and varying degrees of surgical resection or debulking. Pembrolizumab is an immunotherapeutic agent that has demonstrated efficacy in the treatment of metastatic melanoma. The authors present a case of metastatic melanoma to the orbit demonstrating profound pseudoprogression within hours of beginning pembrolizumab therapy, with associated mass effect and vision loss. Systemic corticosteroids, orbital external-beam radiation therapy, and a brief interruption in pembrolizumab halted expansion of the orbital lesion and vision loss. This case illustrates that rapid increase in orbital melanoma size, due to acute inflammatory response, may occur after initiation of systemic pembrolizumab therapy. Clinicians should be aware of this pseudoprogression mechanism as a potential cause of vision compromise in metastatic orbital melanoma. Prompt recognition and treatment may be needed to prevent permanent vision loss.

View details for DOI 10.1097/IOP.0000000000001543

View details for PubMedID 32134764

Progress Towards Parity: Female Representation in the American Society of Ophthalmic Plastic and Reconstructive Surgery. Ophthalmic plastic and reconstructive surgery Azad, A. D., Rosenblatt, T. R., Chandramohan, A., Fountain, T. R., Kossler, A. L. 2020


PURPOSE: To report female representation within the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) at all levels of career achievement over 50 years.METHODS: Data were extrapolated from published ASOPRS directories and the 50th anniversary booklet. Fellowship, membership, leadership, and awards data were evaluated over 5 decades. Comparisons were made between the first and second 25 years, proportions of early and late career achievements, and time to career progression between males and females.RESULTS: During the first decade, 5.6% of ASOPRS fellows were female (n = 2), which rose to 6.6% (n = 8), 17.6% (n = 32), 22.4% (n = 35), and 39.4% (n = 97) in the second, third, fourth, and fifth decades, respectively. These patterns were echoed in ASOPRS membership. When comparing the first half (1969-1994) to the second half (1995-2018), fellowship (10.5% vs. 30.0%, p < 0.001), membership (8.0% vs. 30.3%, p < 0.001), early career awards (5.6% vs. 28.9%, p = 0.047), program directorship (0.0% vs. 15.7%, p = 0.017), and executive committee female representation (4.5% vs. 16.8%, p < 0.001) increased significantly. However, females were proportionally underrepresented as program directors (p = 0.003), late career award winners (p = 0.001), executive committee members (p < 0.001), and presidents (p = 0.020). Among those reaching leadership positions, females took longer than males to become program directors by a median of 4 years (p = 0.025).CONCLUSIONS: There has been a steady increase in female representation in ASOPRS fellowship training and membership. While significant progress has been made, growth in female leadership and award recognition is still needed.

View details for DOI 10.1097/IOP.0000000000001764

View details for PubMedID 32675720

Retrospective Analysis of Incidence Rates of Benign and Malignant Eyelid Lesions at a San Francisco Bay Area Tertiary Hospital Gali, H. E., Kim, Y., Lian, R., Chea, L., Ahmadian, S., Kossler, A., Erickson, B., Born, D., Basham, R., Egbert, P., Lin, J. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2020
Treatment Pathways and Geographic Variation in Thyroid Eye Disease Patient Care: Analysis of Commercially-Insured Patients, 2008-2016 Azad, A., Kossler, A. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2020
Corneal Neurotization: A Review of Pathophysiology and Outcomes. Ophthalmic plastic and reconstructive surgery Park, J. K., Charlson, E. S., Leyngold, I. n., Kossler, A. L. 2020


The objective of this study is to provide a systematic review of the clinical outcomes of corneal neurotization and present the pathophysiology of corneal wound healing, neurotrophic keratopathy, and corneal neurotization.A literature review of published articles and meeting abstracts between December 2008 and February 2019 in the English language with the terms "corneal neurotization," "corneal neurotisation," "corneal reinnervation," and "neurotrophic keratopathy" was performed. Reported clinical data before and after corneal neurotization, and surgical techniques, were collected and analyzed.A total of 54 eyes that underwent corneal neurotization were identified. Final Logarithm of the Minimum Angle of Resolution (logMAR) best-corrected visual acuity improved to 0.85 (standard deviation [SD] = 0.65) from 1.25 (SD = 0.71) with a mean improvement of 0.41 (SD = 0.55; p < 0.0001). Central corneal sensation measured using Cochet-Bonnet esthesiometer improved from 2.18 mm (SD = 0.4) to 40.10 mm (SD = 18.66) with a mean filament length change of 38.00 mm (SD = 18.95; p < 0.0001). The median time to the reported maximal sensation return was 8 months (interquartile range 6-10). The most common reported limitation to visual recovery was corneal scarring (31.5%). Children (ages 0-17 years) as compared with adults (ages 18-82 years) had significantly greater final central corneal sensation esthesiometry readings, central corneal sensation return, and improvement in the logMAR best-corrected visual acuity (p < 0.011).Neurotrophic keratopathy disturbs the homeostatic balance of trophic factors and trigeminal nerve reflexes needed to support ocular surface health and corneal healing. Corneal neurotization can significantly improve corneal sensation and visual acuity and should be considered for the treatment of refractory neurotrophic keratopathy, especially in pediatric populations.

View details for DOI 10.1097/IOP.0000000000001583

View details for PubMedID 31923091

Corneal Neurotization: A Surgical Treatment for Neurotrophic Keratopathy. Journal of neuro-ophthalmology : the official journal of the North American Neuro-Ophthalmology Society Kolseth, C. M., Charlson, E. S., Kossler, A. L. 2020

View details for DOI 10.1097/WNO.0000000000000879

View details for PubMedID 32349065

Radiation-Induced Hyalinizing Clear Cell Carcinoma of the Orbit. Ophthalmic plastic and reconstructive surgery Topping, K. L., Ortiz, A. n., Lin, J. H., Kossler, A. L. 2020


Radiation-induced malignancy is rare, occurring in approximately 0.4%-1.0% of patients receiving external beam radiation therapy. Sarcomas and squamous cell carcinomas are among the most common types of cancers to occur. A 74-year-old woman presented with redness and swelling in the right periorbital region. She had history of multiple recurrent ameloblastoma of the right maxilla, invading the right orbital floor status post 4 surgical resections and 66 Gray external beam radiotherapy 5 years prior. MRI showed a poorly circumscribed mass involving the inferior and lateral orbit. Orbital biopsy revealed clear cell carcinoma with hyalinizing sclerosis and Ewing sarcoma breakpoint region 1 gene arrangement. Due to the extent of orbital disease and presence of perineural invasion, she underwent orbital exenteration. Hyalinizing clear cell carcinoma, a rare cancer, has not been reported to occur in the orbit following radiation. This case highlights the importance of lifetime monitoring in patients who have undergone radiation therapy.

View details for DOI 10.1097/IOP.0000000000001708

View details for PubMedID 32427738

Microsurgical Resection of an Orbital Arteriovenous Malformation With Intraoperative Digital Subtraction Angiography. Ophthalmic plastic and reconstructive surgery Rosenblatt, T. R., Myung, D. n., Fischbein, N. J., Steinberg, G. K., Kossler, A. L. 2020

View details for DOI 10.1097/IOP.0000000000001815

View details for PubMedID 32976328

Teprotumumab for Dysthyroid Optic Neuropathy: Early Response to Therapy. Ophthalmic plastic and reconstructive surgery Sears, C. M., Azad, A. D., Dosiou, C. n., Kossler, A. L. 2020


A 45-year-old male presented with active progressive thyroid eye disease refractory to intravenous steroids and right orbital radiation. Visual acuity, left relative afferent pupillary defect, and Humphrey visual field defects were consistent with worsening left dysthyroid optic neuropathy. Orbital MRI demonstrated extraocular muscle enlargement and effacement of the left optic nerve sheath. After 2 infusions of teprotumumab, the patient's visual acuity, relative afferent pupillary defect, Humphrey visual fields, proptosis, and extraocular muscle size improved. This is the first report of dysthyroid optic neuropathy responsive to teprotumumab, and it supports the need for further studies to better understand the role of teprotumumab in treating sight-threatening thyroid eye disease.

View details for DOI 10.1097/IOP.0000000000001831

View details for PubMedID 32976335

Chronic Electrical Stimulation for Tear Secretion: Lacrimal vs. anterior ethmoid nerve. The ocular surface Kossler, A. L., Brinton, M., Patel, Z. M., Dalal, R., Ta, C. N., Palanker, D. 2019


PURPOSE: To evaluate and compare the effect of lacrimal nerve stimulation (LNS) and anterior ethmoid nerve stimulation (AENS) on aqueous tear secretion, and tissue condition following chronic implantation.METHODS: A neurostimulator was implanted in rabbits adjacent to the (1) lacrimal nerve, and (2) anterior ethmoid nerve. Tear volume was measured with Schirmer test strips after stimulation (2.3-2.8mA pulses at 30Hz for 3-5min), and scores were compared to sham stimulation. Lacrimal gland and nasal septal tissue were evaluated histologically after chronic stimulation (2 weeks-7 months).RESULTS: LNS increases tear volume by 32% above sham (p<0.05, n=5), compared with 133% for AENS (p0.01, n=6). AENS also significantly increases tear secretion in the fellow, non-stimulated eye (p0.01, n=6), as expected from the tearing reflex pathway. Histologically, chronic LNS is well tolerated by surrounding tissues while chronic AENS results in nasal mucosal fibrosis and implant extrusion within 3 weeks.CONCLUSIONS: AENS is significantly more effective than LNS at enhancing aqueous tear secretion, including the fellow eye. The lacrimal implant is well tolerated, while the nasal implant requires further design optimization to improve tolerability.

View details for DOI 10.1016/j.jtos.2019.08.012

View details for PubMedID 31476515

Incidence of Perineural Invasion with Hedgehog Pathway Inhibitors in Orbital and Periorbital Basal Cell Carcinoma Chandramohan, A., Nair, A., Chang, A., Kossler, A. L. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2019
Neurostimulation for tear production. Current opinion in ophthalmology Park, J. K., Cremers, S. n., Kossler, A. L. 2019; 30 (5): 38694


Dry eye disease (DED) is a chronic multifactorial disease that affects millions of people worldwide. Despite ongoing research, treatment for DED remains a challenge. Neurostimulation for tear production is a rapidly evolving field that culminated in the development of the intranasal tear neurostimulator (ITN). In this article, we review the neuroanatomy and pathophysiology of tear production and the evolution of neurostimulation for the treatment of DED.The ITN was approved for commercial use in April 2017. This innovation stemmed from the success of lacrimal nerve and anterior ethmoid nerve stimulation animal studies. Since then, numerous pilot studies and multicenter randomized controlled trials demonstrate increased aqueous tear production, improved DED-related symptoms, and device safety. Recent studies also report the positive effects of intranasal stimulation on mucin and lipid secretion.Neurostimulation for enhanced tear production is a promising new treatment option for DED. Stimulation of the lacrimal nerve and anterior ethmoid nerve both effectively increase tear volume. The ITN is a noninvasive device that effectively increases aqueous tear volume and may improve tear composition, including mucin and lipid concentrations. Further studies are needed to determine proper patient selection and the long-term efficacy of neurostimulation for DED.

View details for DOI 10.1097/ICU.0000000000000590

View details for PubMedID 31393326

Orbital, eyelid, and nasopharyngeal silicone oil granuloma presenting as ptosis & pseudo-xanthelasma. American journal of ophthalmology case reports Powers, M. A., Wood, E. H., Erickson, B. P., Singh, K., Sanislo, S. R., Kossler, A. L. 2018; 11: 4548


Purpose: To highlight the presentation and management of a patient with eyelid, orbital and nasopharyngeal silicone oil migration through a glaucoma drainage implant presenting as pseudo-xanthelasma and ptosis.Observations: A 68-year male presented with unilateral ptosis and presumed xanthelasma. He had a history of glaucoma drainage implant surgery, pseudophakia, and multiple retinal detachment repairs with silicone oil. During ptosis repair it was discovered that his presumed xanthelasma was in fact an eyelid silicone granuloma. Additional work up revealed silicone infiltration of the eyelids, orbits, and nasopharynx, resulting from emulsified silicone oil leakage through his glaucoma valve implant.Conclusions and Importance: Silicone oil may emulsify with time, with potential egress via a glaucoma filtration device. Clinicians should be alert for eyelid, orbital and sinonasal findings that may indicate occult migration.

View details for PubMedID 29978139

Orbital and chorioretinal manifestations of Erdheim-Chester disease treated with vemurafenib. American journal of ophthalmology case reports Huang, L. C., Topping, K. L., Gratzinger, D., Brown, R. A., Martin, B. A., Silva, R. A., Kossler, A. L. 2018; 11: 15863


Purpose: We report a patient with severe multi-organ dysfunction of unknown origin who presented with bilateral orbital and chorioretinal manifestations that led to the diagnosis of Erdheim-Chester Disease (ECD).Observations: ECD is a rare, histiocytic, proliferative disorder characterized by multi-systemic organ involvement that has historically lacked effective therapy. Our patient underwent genetic testing that was positive for the BRAF V600E mutation; therefore, the patient was treated with vemurafenib.Conclusions and importance: This case demonstrates the rare orbital and intraocular manifestations of ECD and the unfortunate impact of a delayed diagnosis, the importance of early gene therapy testing for management decisions, and the utilization of targeted directed therapy to improve visual outcomes and quality of life.

View details for PubMedID 30094395

Hedgehog Pathway Inhibitors as Neoadjuvant Therapy for Orbital/Periorbital Basal Cell Carcinoma Chandramohan, A., Nair, A., Chang, A. L., Kossler, A. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2018
Fundus Flavoprotein Autofluorescence in Compressive Optic Neuropathy Topping, K., Cockerham, K., Kossler, A. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2018
Disseminated silicone granulomatosis in the face and orbit. American journal of ophthalmology case reports Chen, T. A., Mercado, C. L., Topping, K. L., Erickson, B. P., Cockerham, K. P., Kossler, A. L. 2018; 10: 3234


Purpose: To report a case of disseminated silicone granulomatosis presenting with ptosis, proptosis and vision loss.Observations: A 56-year-old female presented with ptosis, proptosis, and vision loss and was noted to have palpable, erythematous masses involving the orbit, face, trunk, and body. She had a history of bilateral silicone breast implants and cosmetic facial filler injections. Orbital biopsy demonstrated non-caseating granulomas with foreign-body giant cells and vacuoles containing material consistent with silicone. Removal of the patient's breast implants and systemic immunosuppression led to dramatic granuloma regression.Conclusions: Silicone can induce a severe, systemic inflammatory response and should be considered in the differential for facial and periorbital granulomas in patients with a history of silicone breast implants. Management of disseminated silicone granulomatosis is challenging and requires multimodal treatment with silicone removal and systemic immunomodulation.

View details for PubMedID 29780909

Enhanced natural tearing by electrical stimulation of the anterior ethmoid nerve Brinton, M., Kossler, A., Patel, Z., Loudin, J., Franke, M., Ta, C., Palanker, D. V. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2017
Enhanced Tearing by Electrical Stimulation of the Anterior Ethmoid Nerve INVESTIGATIVE OPHTHALMOLOGY & VISUAL SCIENCE Brinton, M., Kossler, A. L., Patel, Z. M., Loudin, J., Franke, M., Ta, C. N., Palanker, D. 2017; 58 (4): 2341-2348


Electrical neurostimulation enhances tear secretion, and can be applied to treatment of dry eye disease. Using a chronic implant, we evaluate the effects of stimulating the anterior ethmoid nerve on the aqueous, lipid, and protein content of secreted tears.Neurostimulators were implanted beneath the nasal mucosa in 13 New Zealand white rabbits. Stimulations (2.3-2.8 mA pulses of 75-875 s in duration repeated at 30-100 Hz for 3 minutes) were performed daily, for 3 weeks to measure changes in tear volume (Schirmer test), osmolarity (TearLab osmometer), lipid (Oil-Red-O staining), and protein (BCA assay, mass spectrometry).Stimulation of the anterior ethmoid nerve in the frequency range of 30 to 90 Hz increased tear volume by 92% to 133% (P 0.01). Modulating the treatment with 50% duty cycle (3 seconds of stimulation repeated every 6 seconds) increased tear secretion an additional 23% above continuous stimulation (P 0.01). Tear secretion returned to baseline levels within 7 minutes after stimulation ended. Tear film osmolarity decreased by 7 mOsmol/L, tear lipid increased by 24% to 36% and protein concentration increased by 48% (P 0.05). Relative abundance of the lacrimal gland proteins remained the same, while several serum and corneal proteins decreased with stimulation (P 0.05).Electrical stimulation of the anterior ethmoid nerve increased aqueous tear volume, reduced tear osmolarity, added lipid, and increased the concentration of normal tear proteins. Human studies with an intranasal stimulator should verify these effects in patients with aqueous- and lipid-deficient forms of dry eye disease.

View details for DOI 10.1167/iovs.16-21362

View details for PubMedID 28431436

Current Trends in Upper and Lower Eyelid Blepharoplasty Among American Society of Ophthalmic Plastic and Reconstructive Surgery Members. Ophthalmic plastic and reconstructive surgery Kossler, A. L., Peng, G. L., Yoo, D. B., Azizzadeh, B., Massry, G. G. 2017


To assess current practice patterns for management of upper and lower eyelid blepharoplasty by active American Society of Ophthalmic Plastic and Reconstructive Surgery members.An invitation to participate in a web-based anonymous survey was sent to the active American Society of Ophthalmic Plastic and Reconstructive Surgery membership via email. The survey consists of 34 questions, both multiple choice and free response, regarding upper and lower eyelid blepharoplasty surgery. Practice patterns for both aesthetic and functional blepharoplasty are assessed.Thirty-four percent (161/472) of American Society of Ophthalmic Plastic and Reconstructive Surgery members polled responded to the survey. Members perform an average of 196 upper eyelid, 46 lower eyelid, and 53 four-eyelid blepharoplasty procedures per year, with 70% of cases being functional and 30% purely aesthetic. Most members prefer monitored care (71%) to local (21%) or general (8%) anesthesia. Eighty-nine percent of surgeons use topical antibiotics after surgery, erythromycin being the most common (51%). Fourteen percent of members use postoperative oral antibiotics, with cephalexin (81%) being most common. In upper eyelid blepharoplasty, orbicularis muscle is excised by 86% of respondents. Orbital fat is excised, when deemed appropriate, in 97% of cases, with nasal fat excised most commonly (88%). Less commonly, fat repositioning (36%) and adjunctive fat grafting (33%) are performed. In lower eyelid blepharoplasty, surgeons report using one or more of the following approaches: transconjunctival (96%), transcutaneous (82%), and both transconjunctival and transcutaneous (51%). Common adjunctive procedures include orbital fat excision (99%), fat repositioning (80%), and lateral canthal suspension (96%). Less common adjunctive procedures include laser skin resurfacing (36%) and chemical peels (29%).This report outlines contemporary practice patterns among active American Society of Ophthalmic Plastic and Reconstructive Surgery members in the management of upper and lower eyelid blepharoplasty. It is important to quantify such data periodically to update the membership as to how this common surgical procedure is approached. This also allows eyelid surgeons to compare their practice patterns with a national group specializing in such surgery.

View details for DOI 10.1097/IOP.0000000000000849

View details for PubMedID 28151825

Silicone Oil-Induced Nasal Polyposis: A Case Report. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Patel, V. S., Hwang, P. H., Kossler, A. L., Choby, G. n. 2017: 194599817728896

View details for PubMedID 28871877

Exaggerated Oculocardiac Reflex Elicited by Local Anesthetic Injection of an Empty Orbit: A Case Report. A & A case reports Nicholson, D. n., Kossler, A. n., Topping, K. n., Stary, C. M. 2017


We report the first description of oculocardiac reflex elicited with injection of local anesthetic in an empty orbit, and highlight clinical indicators for patients that may be at risk for an exaggerated oculocardiac reflex. We describe a patient with prior head and eye trauma treated for anophthalmic socket reconstruction at an outpatient eye surgery center. Injection of local anesthetic into the empty orbit induced an extended sinus arrest. This exaggerated response was avoided in a subsequent surgery by pretreatment with high-dose anticholinergics.

View details for DOI 10.1213/XAA.0000000000000609

View details for PubMedID 28767475

Lateral Canthal Tendon Disinsertion: Clinical Characteristics and Anatomical Correlates. Ophthalmic plastic and reconstructive surgery Shriver, E. M., Erickson, B. P., Kossler, A. L., Tse, D. T. 2016; 32 (5): 378-385


To highlight features of lateral canthal tendon disinsertion (LCTD), provide an algorithm for systematic assessment, and describe the anatomic genesis of signs and symptoms.Retrospective case series of consecutive patients with lateral canthal tendon disinsertion, who underwent lateral canthal tendon fixation by a single surgeon (DTT) between 2004 and 2011.One hundred and seventeen eyes in 90 patients underwent lateral canthal tendon fixation. Average age was 69.3 17.9 years. Twenty-three percentage of eyes had undergone lower eyelid blepharoplasty and 52% had undergone lateral canthal tightening; 35% had no previous periocular surgery. Patients with purely involutional lateral canthal tendon disinsertion were significantly older (76.1 7.8 years of age; p < 0.03). Six key features associated with lateral canthal tendon disinsertion were identified. On static evaluation: 1) a blunted or vertically displaced lateral canthal angle; 2) a narrow horizontal fissure with reduced temporal scleral triangle; and 3) pseudo eyelid retraction. On dynamic evaluation with attempted closure: 4) medial and inferior movement of the lateral commissure; 5) incomplete apposition of the eyelid margins in the absence of anterior lamellar shortage; and 6) temporal eyelid imbrication. Improved blink dynamics with manual lateral canthal tendon complex repositioning ("the thumb test") predicted a favorable outcome with surgical tightening in 95.7% of cases.Lateral canthal tendon disinsertion results in altered eyelid fissure symmetry, blink dynamics, and lacrimal pump function. The authors recommend the mnemonic-A.B.C.: for Aperture configuration, Blink dynamics, and eyelid Closure-to structure the examination of all symptomatic patients. Manual restoration of the disinserted lateral canthal tendon with the "thumb test" predicts favorable outcomes with surgical fixation.

View details for DOI 10.1097/IOP.0000000000000552

View details for PubMedID 26398240

The Locking Y Lateral Canthopexy With Osseous Integration: Clinical Experience and Surgical Technique. Ophthalmic plastic and reconstructive surgery Kossler, A. L., Erickson, B. P., Shriver, E. M., Tse, D. T. 2016; 32 (5): 386-392


To describe a surgical technique to correct lateral canthal tendon disinsertion with a strabismus surgery-inspired locking capture of the tendon complex and osseous integration via drill holes.Retrospective interventional case series including all patients with lateral canthal tendon disinsertion who underwent locking Y lateral canthopexy with drill hole reinforcement by 1 surgeon (D.T.T.) between 2006 and 2011. Outcome measures included resolution of presenting ocular symptoms, improved blink dynamics and lid closure, correction of lagophthalmos and exposure keratopathy, and need for further surgery.A total of 53 lateral canthopexies with osseous integration were performed in 42 patients who fulfilled clinical criteria for lateral canthal tendon disinsertion. The population was biased toward treatment failures; 81% of eyes (43/53) had a history of prior lateral canthal tightening, and of these 30.2% (16/53) had undergone 3 or more procedures. Postoperatively, all eyes demonstrated improved eyelid position and blink mechanics, and 83% (44/53) had subjective resolution of epiphora and ocular irritation. Lagophthalmos was fully corrected in 95% (19/20) of cases, and corneal staining resolved in 88% (14/16). With a mean follow-up period of 24 months, 3.7% of eyes (2/53) required additional lateral canthal tightening.The locking Y lateral canthopexy is an effective and durable method for repositioning the lateral canthal tendon complex to improve blink dynamics, eyelid closure, and cosmesis. Even in a population heavily biased toward treatment failure, clinical results are excellent and the reoperation rate is low.

View details for DOI 10.1097/IOP.0000000000000553

View details for PubMedID 26359700

Electronic enhancement of tear secretion. Journal of neural engineering Brinton, M., Chung, J. L., Kossler, A., KooK, K. H., Loudin, J., Franke, M., Palanker, D. 2016; 13 (1): 016006-?


To study electrical stimulation of the lacrimal gland and afferent nerves for enhanced tear secretion, as a potential treatment for dry eye disease. We investigate the response pathways and electrical parameters to safely maximize tear secretion.We evaluated the tear response to electrical stimulation of the lacrimal gland and afferent nerves in isofluorane-anesthetized rabbits. In acute studies, electrical stimulation was performed using bipolar platinum foil electrodes, implanted beneath the inferior lacrimal gland, and a monopolar electrode placed near the afferent ethmoid nerve. Wireless microstimulators with bipolar electrodes were implanted beneath the lacrimal gland for chronic studies. To identify the response pathways, we applied various pharmacological inhibitors. To optimize the stimulus, we measured tear secretion rate (Schirmer test) as a function of pulse amplitude (1.5-12 mA), duration (0.1-1 ms) and repetition rate (10-100 Hz).Stimulation of the lacrimal gland increased tear secretion by engaging efferent parasympathetic nerves. Tearing increased with stimulation amplitude, pulse duration and repetition rate, up to 70 Hz. Stimulation with 3 mA, 500 s pulses at 70 Hz provided a 4.5 mm (125%) increase in Schirmer score. Modulating duty cycle further increased tearing up to 57%, compared to continuous stimulation in chronically implanted animals (36%). Ethmoid (afferent) nerve stimulation increased tearing similar to gland stimulation (3.6 mm) via a reflex pathway. In animals with chronically implanted stimulators, a nearly 6 mm increase (57%) was achieved with 12-fold less charge density per pulse (0.06-0.3 C mm(-2) with 170-680 s pulses) than the damage threshold (3.5 C mm(-2) with 1 ms pulses).Electrical stimulation of the lacrimal gland or afferent nerves may be used as a treatment for dry eye disease. Clinical trials should validate this approach in patients with aqueous tear deficiency, and further optimize electrical parameters for maximum clinical efficacy.

View details for DOI 10.1088/1741-2560/13/1/016006

View details for PubMedID 26655141

Objective surgical assessments for residents and experienced surgeons in the Yelp Era JOURNAL OF CATARACT AND REFRACTIVE SURGERY Cremers, S. L., Kossler, A. L., Ciolino, J., Henderson, B. A. 2015; 41 (11): 2593-2595

View details for Web of Science ID 000368051300035

View details for PubMedID 26703521

Implanted Microelectronic Stimulator Increases Tear Secretion in Rabbits Brinton, M., Chung, J., Kossler, A., Kook, K., Loudin, J., Ta, C., Palanker, D. V. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2015
Neurostimulation of the lacrimal nerve for enhanced tear production. Ophthalmic plastic and reconstructive surgery Kossler, A. L., Wang, J., Feuer, W., Tse, D. T. 2015; 31 (2): 145-151


To design a proof-of-concept study to assess the effect of lacrimal nerve stimulation (LNS) with an implantable pulse generator (IPG) to increase aqueous tear production.Experimental animal study design of 6 Dutch Belted rabbits. Ultra high-resolution optical coherence tomography (UHR-OCT) quantified tear production by measuring the baseline tear volume of each rabbit's OD and OS. A neurostimulator was implanted adjacent to the right lacrimal nerve. After 2 minutes of LNS (100 s, 1.6 mA, 20 Hz, 5-8 V), the tear volumes were measured with UHR-OCT. The change in tear volume was quantified and compared with the nonstimulated OS. Three rabbits underwent chronic LNS (100 s, 1.6 mA, 10 Hz, 2 V) and their lacrimal glands were harvested for histopathologic analysis.The UHR-OCT imaging of the OD tear volume showed a 441% average increase in tear production after LNS as a percent of baseline. After stimulation, OD had statistically significant greater increase in tear volumes than OS (p = 0.028, Wilcoxon test). Poststimulation OD tear volumes were significantly greater compared with baseline (p = 0.028, Wilcoxon test). Histopathologic examination of the lacrimal glands showed no discernible tissue damage from chronic neurostimulation. In addition, there were no gross adverse effects on the general well-being of the animals due to chronic stimulation.LNS with an IPG appears to increase aqueous tear production. Chronic LNS showed no histopathologic lacrimal gland damage. This study suggests that LNS is a promising new treatment strategy to increase aqueous tear production.

View details for DOI 10.1097/IOP.0000000000000234

View details for PubMedID 25126767

View details for PubMedCentralID PMC4329098

Electrical Stimulation of the Lacrimal Gland in Rabbits Brinton, M., Chung, J., Kossler, A., Loudin, J., Ta, C., Palanker, D. V. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2014
Author reply. Ophthalmology Tse, D. T., Kossler, A. L., Feuer, W. J., Benedetto, P. W. 2014; 121 (1): e8e10

View details for DOI 10.1016/j.ophtha.2013.11.012

View details for PubMedID 24268860

Long-Term Outcomes of Neoadjuvant Intra-arterial Cytoreductive Chemotherapy for Lacrimal Gland Adenoid Cystic Carcinoma. Ophthalmology Tse, D. T., Kossler, A. L., Feuer, W. J., Benedetto, P. W. 2013


PURPOSE: To compare the long-term outcomes after intra-arterial cytoreductive chemotherapy (IACC) with conventional treatment for lacrimal gland adenoid cystic carcinoma (ACC). DESIGN: Retrospective case series. PARTICIPANTS: Nineteen consecutive patients treated with IACC, followed by orbital exenteration, chemoradiotherapy, and intravenous chemotherapy. INTERVENTIONS: Analyses of the histologic characteristics of biopsy specimens, extent of disease at the time of diagnosis, diagnostic surgical procedures, incidence of locoregional recurrences or distant metastases, disease-free survival time, response to IACC, tumor margins at definitive surgery, and toxicity and complications. MAIN OUTCOME MEASURES: Disease relapse, disease-free survival, and chemotherapeutic complications. RESULTS: Eight patients with an intact lacrimal artery had significantly better outcomes for survival (100% vs. 28.6% at 10 years), cause-specific mortality, and recurrences (all P = 0.002, log-rank test) than conventionally treated patients from the University of Miami Miller School of Medicine. These 8 patients (group 1) had cumulative 10-year disease-free survival of 100% compared with 50% for 11 patients (group 2) who had an absence of the lacrimal artery or deviated from the treatment protocol (P = 0.035) and 14.3% for conventionally treated patients (P<0.001). Likewise, group 2 was associated with lower cause-specific mortality than the institutional comparator group (P = 0.038). Prior tumor resection with lateral wall osteotomy, delay in IACC implementation or exenteration, and failure to adhere to protocol are risk factors for suboptimal outcomes. CONCLUSIONS: Neoadjuvant IACC seems to improve overall survival and decrease disease recurrence. An intact lacrimal artery, no disruption of bone barrier or tumor manipulation other than incisional biopsy, and protocol compliance are factors responsible for favorable outcomes. The chemotoxicity complication rate is limited and manageable. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

View details for DOI 10.1016/j.ophtha.2013.01.027

View details for PubMedID 23582989

Hordeolum, Chalazion and Blepharitis Primary Care: A Collaborative Practice Kossler, A., Banta, J. edited by Buttaro, T. M., Trybulski, J., Bailey, P. P., Sandberg-Cook, J. Mosby. 2012; 4th


The American Board of Ophthalmology in conjunction with the Accreditation Council for Graduate Medical Education has mandated the systematic assessment of surgical competence of ophthalmology residents at all residency programs. We present a tool complementary to the Objective Assessment of Skills in Intraocular Surgery (OASIS) to assess residents' surgical competence.Twenty experts in resident education, including the chiefs of all ophthalmology services and the chief resident at the Harvard Medical School Department of Ophthalmology.A 1-page subjective evaluation form was developed in conjunction with the Objective Assessment of Skills in Intraocular Surgery evaluation form to assess the surgical skills of residents. A panel of surgeons at the Harvard Medical School Department of Ophthalmology at the Massachusetts Eye and Ear Infirmary reviewed the form and provided constructive feedback.Experts' comments were incorporated, establishing face and content validity.The Global Rating Assessment of Skills in Intraocular Surgery (GRASIS) has face and content validity. It can be used to assess a resident's surgical care of patients as well as a resident's surgical knowledge, preparedness, and interpersonal skills. Reliability and predictive validity will be determined at our institution. We believe the GRASIS evaluation form will be a valuable tool in conjunction with the OASIS evaluation form for assessing ophthalmology residents' surgical skills at other residency programs as well.

View details for DOI 10.1016/j.ophtha.2005.05.010

View details for Web of Science ID 000232299200003

View details for PubMedID 16102834

Dacryocystitis and Nasolacrimal Duct Obstruction Primary Care: A Collaborative Practice Kossler, K. L., Banta, J. edited by Buttaro, T. M., Bailey, P. P., Trybulski, J., Sandberg-Cook, J. Mosby. 2012


Observations in primates and patients with unilateral spatial neglect have suggested that patching of the eye ipsilateral to the injury and contralateral to the neglected space can sometimes improve attention to the neglected space. Investigators have generally attributed the effects of monocular eye patching to activation of subcortical centers that interact with cortical attentional systems. Eye patching is thought to produce preferential activation of attentional systems contralateral to the viewing eye. In this study we examined the effect of monocular eye patching on attentional biases in normal subjects. When normal subjects bisect vertical (radial) lines using both eyes, they demonstrate a far attentional bias, misbisecting lines away from their body. In a monocular viewing experiment, we found that the majority of subjects, who were right eye dominant, had relatively nearer bisections and a diminished far bias when they used their right eye (left eye covered) compared with when they used their left eye (right eye covered). The smaller group of subjects who were left eye dominant had relatively nearer bisections and a diminished far bias when they used their left eye compared with when they used their right eye. In the hemispatial placement experiment, we directly manipulated hemispheric engagement by having subjects perform the same task in right and left hemispace. We found that right eye dominant subjects had a diminished far bias in right hemispace relative to left hemispace. Left eye dominant subjects showed the opposite pattern and had a diminished far bias in left hemispace. For both groups, spatial presentation affected performance more for the non-dominant eye. The results suggest that monocular viewing is associated with preferential activation of attentional systems in the contralateral hemisphere, and that the right hemisphere (at least in right eye dominant subjects) is biased towards far space. Finally, the results suggest that the poorly understood phenomenon of eye dominance may be related to hemispheric specialization for visual attention.

View details for Web of Science ID 000177504900010

View details for PubMedID 12183348

Pediatric Cataract Ophthalmic Surgical Procedures Cremers, S., Lora-Kossler, A., Azar, N. edited by Hersh, P. S., Zagelbaum, B., Cremers, S. Thieme. 2009; 2nd
Time Domain versus Spectral Domain Optical Coherence Tomography (OCT) in the Diagnosis and Treatment of Angioid Streaks Ophthalmology Web Lora-Kossler, A. 2008
Conjunctival Squamous Cell Carcinoma with Intraocular and Intraorbital Invasion Ophthalmology Times Lora-Kossler, A., Johnson, T. 2008
Systemic Multiple Myeloma with Secondary Orbital Plasmacytoma Ophthalmology Times Andrea, L. 2008
Global Rating Assessment of Skills in Intraocular Surgery (GRASIS) OPHTHALMOLOGY Cremers, S. L., Lora, A. N., Ferrufino-Ponce, Z. K. 2005; 112 (10): 1655-1660
Impact of Depressive Illness on Emergency Department Recidivism: A New Approach to the Frequent Flyer Annals of Emergency Medicine Lora-Kossler, A., Simpsom, M., Freed, M., Milzman, D. 2004; 23 (44.4)
Effects of monocular viewing and eye dominance on spatial attention BRAIN Roth, H. L., Lora, A. N., Heilman, K. M. 2002; 125: 2023-2035