Fall 2017 Newsletter

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Fall 2017 Newsletter
7th Residency Announcement

Exciting Residency Announcement!

ACGME approves seventh resident complement; first increase in over 30 years!

Grand Rounds

Grand Rounds and Case Studies

Check out our weekly presentations



USC Ophthalmology Researchers Find More
Effective Treatments For Blinding Eye Diseases


Case Study: A Midsummer Night’s Heme

Luv Patel Moshfeghi cropped
Presenter: Luv Patel, MD Discussant: Andrew Moshfeghi, MD, MBA


  • 31-year-old man with type 2 diabetes presenting with one day of right eye “red floater”

Exam Findings

Figure 1
Figures 1 and 2: Right eye fundus shows diffuse flame and dot-blot hemorrhages with large subhyaloid hemorrhage nasal to disc. There is no subretinal hemorrhage. There is neovascularization of the disc.

Figure 3
Figure 3: Left eye fundus shows rare flame hemorrhage.


Differential Diagnosis

  • Retinal vein occlusion
  • Proliferative diabetic retinopathy
  • Thrombocytopenia
  • Severe anemia
  • Hypertensive retinopathy
  • Hyperviscosity syndrome (leukemias)
  • Sickle cell retinopathy

Additional Investigations

  • Fluorescein angiography
Figure 4
Figure 4: Right eye shows blocking from the hemorrhage, early staining of scattered micro aneurysms; late leakage around optic disc suggestive of neovascularization..



  • Proliferative diabetic retinopathy


  • Microvascular diabetic disease causes ischemia of the retina. Hypoxia-induced growth factors, most notably but not limited to VEGF, are secreted. These growth factors stimulate neovascularization out of the retina. These new vessels use the posterior vitreous as a scaffold. There is a high risk of hemorrhage from these vessels causing diabetic hemorrhages into the vitreous and subhyaloid spaces. There is also a proliferation of fibrous tissue along with neovascularization. The regression of the vessels with persistent fibrous proliferation can lead to complications including tractional retinal detachments.


  • Panretinal photocoagulation (PRP) has been the mainstay of therapy for proliferative diabetic retinopathy for > 35 years. The Diabetic Retinopathy Study (1981) showed that the rate of severe vision loss was reduced by 50% in eyes treated with PRP. There are several side effects of PRP, including post-procedural macular edema, decreased night vision, and loss of peripheral vision.
  • As shown by the Diabetes Control and Complications Trial and UK Prospective Diabetes Study, intensive blood sugar control reduces microvascular complications including diabetic retinopathy.

Prognosis and Future Directions

  • Anti-VEGF therapy, widely used for diabetic macular edema, has recently been suggested as a potential alternate treatment to PRP for proliferative diabetic retinopathy. Protocol S of the Diabetic Retinopathy Clinical Research Network compared initial PRP to a series of ranibizumab injections and monthly monitoring with deferred PRP. This study found that the peripheral visual field[CAC1] sensitivity loss was worse, DME more frequent and vitrectomy more often required in the PRP group. The primary outcome-mean visual acuity letter improvement at 2 years-was +2.8 in the ranibizumab group and +0.2 in the PRP group (95% CI of difference – -0.5 to +5.0). Overall, it was determined that ranibizumab with monthly visits was non-inferior to PRP. The use of anti-VEGF agents as primary treatment, with PRP for rescue, remains an exciting new area of development for PDR treatment with appropriate patient selection.
  • We had an extensive discussion of the risks, benefits and options of anti-VEGF injections with monitoring or prompt PRP. The patient indicated that he may not follow-up as advised and elected prompt PRP therapy. This illustrates one of the greatest practical limitations to Protocol S, the importance of close follow-up. This limitation is especially germane in any patient population where close, reliable follow-up is not possible.


  • Progression of retinopathy with intensive versus conventional treatment in the Diabetes Control and Complications Trial. Diabetes Control and Complications Trial Research Group. Ophthalmology. 1995 Apr;102(4):647-661.
  • Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group. BMJ. 1998;317(7160):703-713.
  • Photocoagulation treatment of proliferative diabetic retinopathy. Clinical application of Diabetic Retinopathy Study (DRS) findings, DRS Report Number 8. Diabetic Retinopathy Study Research Group. Ophthalmology.1981 Jul;88(7):583-600.
  • Panretinal Photocoagulation vs Intravitreous Ranibizumab for Proliferative Diabetic Retinopathy: A Randomized Clinical Trial. Diabetic Retinopathy Clinical Research Network. JAMA. 2015; 314(20):2137-2146.


Section Editors

  • Vivek Patel, MD, Associate Professor of Clinical Ophthalmology, Program Director, vivek.patel@med.usc.edu
  • Jesse Berry, MD, Assistant Professor of Clinical Ophthalmology, Associate Program Director, jesse.berry@med.usc.edu

    Produced by: Monica Chavez, John Daniel, Joseph Yim and Dr. Vivek Patel
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