Bio

Clinical Focus


  • Neurology
  • Neuro-ophthalmology
  • Papilledema, pseudotumor cerebrii, idiopathic intracranial hypertension

Academic Appointments


Administrative Appointments


  • Chair, abstract committee, North American Neuro-ophthalmology Society (2016 - 2018)
  • Vice chair, neuro-ophthalmology & neuro-otology section, American Academy of Neurology (2016 - 2018)

Honors & Awards


  • Sybil Harrington Special Scholar Award, Research to Prevent Blindness (2015)
  • Young Investigator of the Year, North American Neuro-ophthalmology Society (2015)
  • Teacher of the year, Chicago Curriculum in Ophthalmology (2012, 2014)
  • Zeritsky prize for research by a resident, University of Pennsylvania (2009)
  • Biomedical engineering pre-doctoral fellowship, Whitaker Foundation (1998-2003)
  • Science and Technology Award, Canadian Federation of University Women (1998)

Boards, Advisory Committees, Professional Organizations


  • Assistant Editor, Neuro-ophthalmology (2013 - Present)
  • Review Editor, Current Eye Research (2016 - Present)
  • Fellow, American Academy of Neurology (2016 - Present)
  • Fellow, North American Neuro-ophthalmology Society (2016 - Present)

Professional Education


  • fellowship, University of Pennsylvania, Neuro-ophthalmology (2010)
  • board certification, American Board of Psychiatry and Neurology, Adult Neurology (2010)
  • residency, University of Pennsylvania, Neurology (2009)
  • intern, Massachusetts General Hospital, Medicine (2006)
  • MD, Harvard Medical School (2005)
  • PhD (joint program), Harvard-MIT Division of Health Sciences and Technology, Medical Engineering & Medical Physics (2003)
  • PhD, Harvard University, Engineering Sciences (2003)
  • B.Sc. (eng), University of Guelph (Canada), Biological Engineering (1997)

Research & Scholarship

Current Research and Scholarly Interests


Permanent vision loss caused by papilledema, the swelling of the optic nerve heads due to elevation in intracranial pressure (ICP), occurs in 50% of people with idiopathic intracranial hypertension (IIH) as well as individuals with high ICP from other neurological and neurosurgical diseases. One reason that blindness results from IIH, which is a treatable disease, is lack of timely, accurate clinical markers with which to identify those who are at risk of losing vision.

My research program seeks to identify and develop such markers through studies of papilledema physiology in humans affected by IIH. My current studies focus on humans with IIH because this accurately captures both the disease of interest and the target population. The conceptual frameworks that underlie my research program are drawn from my doctoral level engineering training. Using a mechanical (structural) framework I am evaluating the effect of changing intra-cerebral and intra-optic nerve forces from ICP and papilledema on the shape of the optic nerve and retinal blood vessels. Using an electrical (functional) framework I am evaluating patterns of visual pathway dysfunction in papilledema using non-invasive techniques of electrophysiology, pupillary light response and psychophysics. Markers based on both of these frameworks have the potential to capture the dynamics of pathophysiological changes associated with evolving and resolving papilledema with less delay than currently used clinical markers.

My aim is to develop non-invasive structural and functional markers of papilledema physiology that predict visual outcomes in IIH and guide tailored intervention that will improve visual outcomes and prevent blindness. The short-term objective of my research program is to evaluate candidate markers with regards to differences between untreated IIH, treated IIH and normal patients, changes over time in IIH patients receiving treatment, and differences between IIH patients with and without vision loss. The long-term objective of my research program is to elucidate markers of papilledema physiology that can be studied non-invasively and to ascertain their ability to predict future visual function in IIH and guide clinical management.

Other areas of active research include study of peri-operative vision loss and optic neuritis using secondary data analysis techniques. I am actively involved in clinical trials through the Neuro-Ophthalmology Research Disease Investigator Consortium (NORDIC).

Projects


  • Physiologically Based Markers of Idiopathic Intracranial Hypertension, Stanford University

    Location

    Palo Alto, Ca

  • Risk factors for peri-operative vision loss, Stanford University

    Location

    Palo Alto, Ca

    Collaborators

    • Steven Roth, Professor, University of Illinois at Chicago
    • Charlotte Joslin, Associate Professor, University of Illinois at Chicago
    • Daniel Rubin, Assistant Professor, University of Chicago
  • Secondary analysis of the optic neuritis treatment trial data, Stanford University

    Location

    Palo Alto, CA

Teaching

2016-17 Courses


Publications

All Publications


  • The Longitudinal Idiopathic Intracranial Hypertension Trial: Outcomes from Months 6 - 12. American journal of ophthalmology Wall, M., Kupersmith, M. J., Thurtell, M. J., Moss, H. E., Moss, E. A., Auinger, P. 2017

    Abstract

    To determine whether the beneficial effects of acetazolamide (ACZ) in improving vision at 6 months continues to month 12 in participants of the Idiopathic Intracranial Hypertension Treatment Trial (IIHTT).non-randomized clinical study METHODS: In the IIHTT, subjects were randomly assigned to placebo-plus-diet or maximally tolerated dosage of acetazolamide-plus-diet. At 6 months subjects transitioned from study drug to ACZ. This resulted in the following groups 1) ACZ to ACZ; n = 34; 2) placebo to ACZ; n = 35; 3) ACZ to no treatment; n = 16; and 4) placebo to no treatment; n = 11. 96 IIHTT subjects had evaluations at 6 and 12 months. Our main outcome measure was change from month 6 to month 12 in visual field mean deviation with secondary measures being change in papilledema grade, ETDRS scores and quality of life (QoL) measures.The ACZ to ACZ group improved 0.35 dB , p=0.05; placebo subjects with no ACZ improved 0.81 dB MD, p = 0.07 at 12 mos. The other groups improved 0.35 to 0.46 dB MD. Mean improvements in papilledema grade occurred most markedly in the group that exchanged placebo for ACZ (0.91 units, p < 0.001). QoL and headache disability scores showed significant improvements in the placebo group added ACZ.Improvements in MD continued from month 6 to month 12 of the IIHTT in all treatment groups -most marked in the placebo group tapered off study drug. Adding ACZ to the placebo group significantly improved papilledema grade, headache and QoL measures.

    View details for DOI 10.1016/j.ajo.2017.01.004

    View details for PubMedID 28104417

  • Perioperative Retinal Artery Occlusion: Risk Factors in Cardiac Surgery from the United States National Inpatient Sample 1998-2013. Ophthalmology Calway, T., Rubin, D. S., Moss, H. E., Joslin, C. E., Beckmann, K., Roth, S. 2017; 124 (2): 189–96

    Abstract

    To study the incidence and risk factors for retinal artery occlusion (RAO) in cardiac surgery.Retrospective study using the National Inpatient Sample (NIS).The NIS was searched for cardiac surgery. Retinal artery occlusion was identified by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Postulated risk factors based on literature review were included in multivariate logistic models.Diagnosis of RAO.A total of 5 872 833 cardiac operative procedures were estimated in the United States from 1998 to 2013, with 4564 RAO cases (95% confidence interval [95% CI], 4282-4869). Nationally estimated RAO incidence was 7.77/10 000 cardiac operative procedures from 1998 to 2013 (95% CI, 7.29-8.29). Associated with increased RAO were giant cell arteritis (odds ratio [OR], 7.73; CI, 2.78-21.52; P < 0.001), transient cerebral ischemia (OR, 7.67; CI, 5.31-11.07; P < 0.001), carotid artery stenosis (OR, 7.52; CI, 6.22-9.09; P < 0.001), embolic stroke (OR, 4.43; CI, 3.05-6.42; P < 0.001), hypercoagulability (OR, 2.90; CI, 1.56-5.39; P < 0.001), myxoma (OR, 2.43; CI, 1.39-4.26; P = 0.002), diabetes mellitus (DM) with ophthalmic complications (OR, 1.89; CI, 1.10-3.24; P = 0.02), and aortic insufficiency (OR, 1.85; CI, 1.26-2.71; P = 0.002). Perioperative bleeding, aortic and mitral valve surgery, and septal surgery increased the odds of RAO. Negatively associated with RAO were female gender (OR, 0.77; CI, 0.66-0.89; P < 0.001), thrombocytopenia (OR, 0.79; CI, 0.62-1.00; P = 0.049), acute coronary syndrome (OR, 0.72; CI, 0.58-0.89; P = 0.003), atrial fibrillation (OR, 0.82; CI, 0.70-0.95; P = 0.01), congestive heart failure (OR, 0.73; CI, 0.60-0.88; P < 0.001), DM 2 (OR, 0.74; CI, 0.61-0.89; P = 0.001), and smoking (OR, 0.82; CI, 0.70-0.97; P = 0.02).Risk factors for RAO in cardiac surgery include giant cell arteritis, carotid stenosis, stroke, hypercoagulable state, and DM with ophthalmic complications; associated with lower risk were female gender, thrombocytopenia, acute coronary syndrome, atrial fibrillation, congestive heart failure, DM 2, and smoking. Surgery in which the heart was opened (e.g., septal repair) versus surgery in which it was not (e.g., CABG) and perioperative bleeding increased the risk of RAO.

    View details for DOI 10.1016/j.ophtha.2016.10.025

    View details for PubMedID 27914836

  • Ischemic Optic Neuropathy in Cardiac Surgery: Incidence and Risk Factors in the United States from the National Inpatient Sample 1998 to 2013. Anesthesiology Rubin, D. S., Matsumoto, M. M., Moss, H. E., Joslin, C. E., Tung, A., Roth, S. 2017

    Abstract

    Ischemic optic neuropathy is the most common form of perioperative visual loss, with highest incidence in cardiac and spinal fusion surgery. To date, potential risk factors have been identified in cardiac surgery by only small, single-institution studies. To determine the preoperative risk factors for ischemic optic neuropathy, the authors used the National Inpatient Sample, a database of inpatient discharges for nonfederal hospitals in the United States.Adults aged 18 yr or older admitted for coronary artery bypass grafting, heart valve repair or replacement surgery, or left ventricular assist device insertion in National Inpatient Sample from 1998 to 2013 were included. Risk of ischemic optic neuropathy was evaluated by multivariable logistic regression.A total of 5,559,395 discharges met inclusion criteria with 794 (0.014%) cases of ischemic optic neuropathy. The average yearly incidence was 1.43 of 10,000 cardiac procedures, with no change during the study period (P = 0.57). Conditions increasing risk were carotid artery stenosis (odds ratio, 2.70), stroke (odds ratio, 3.43), diabetic retinopathy (odds ratio, 3.83), hypertensive retinopathy (odds ratio, 30.09), macular degeneration (odds ratio, 4.50), glaucoma (odds ratio, 2.68), and cataract (odds ratio, 5.62). Female sex (odds ratio, 0.59) and uncomplicated diabetes mellitus type 2 (odds ratio, 0.51) decreased risk.The incidence of ischemic optic neuropathy in cardiac surgery did not change during the study period. Development of ischemic optic neuropathy after cardiac surgery is associated with carotid artery stenosis, stroke, and degenerative eye conditions.

    View details for DOI 10.1097/ALN.0000000000001533

    View details for PubMedID 28244936

  • Perioperative Visual Loss in Spine Fusion Surgery: Ischemic Optic Neuropathy in the United States from 1998 to 2012 in the Nationwide Inpatient Sample. Anesthesiology Rubin, D. S., Parakati, I., Lee, L. A., Moss, H. E., Joslin, C. E., Roth, S. 2016; 125 (3): 457-464

    Abstract

    Perioperative ischemic optic neuropathy (ION) causes visual loss in spinal fusion. Previous case-control studies are limited by study size and lack of a random sample. The purpose of this study was to study trends in ION incidence in spinal fusion and risk factors in a large nationwide administrative hospital database.In the Nationwide Inpatient Sample for 1998 to 2012, procedure codes for posterior thoracic, lumbar, or sacral spine fusion and diagnostic codes for ION were identified. ION was studied over five 3-yr periods (1998 to 2000, 2001 to 2003, 2004 to 2006, 2007 to 2009, and 2010 to 2012). National estimates were obtained using trend weights in a statistical survey procedure. Univariate and Poisson logistic regression assessed trends and risk factors.The nationally estimated volume of thoracic, lumbar, and sacral spinal fusion from 1998 to 2012 was 2,511,073. ION was estimated to develop in 257 patients (1.02/10,000). The incidence rate ratio (IRR) for ION significantly decreased between 1998 and 2012 (IRR, 0.72 per 3 yr; 95% CI, 0.58 to 0.88; P = 0.002). There was no significant change in the incidence of retinal artery occlusion. Factors significantly associated with ION were age (IRR, 1.24 per 10 yr of age; 95% CI, 1.05 to 1.45; P = 0.009), transfusion (IRR, 2.72; 95% CI, 1.38 to 5.37; P = 0.004), and obesity (IRR, 2.49; 95% CI, 1.09 to 5.66; P = 0.030). Female sex was protective (IRR, 0.30; 95% CI, 0.16 to 0.56; P = 0.0002).Perioperative ION in spinal fusion significantly decreased from 1998 to 2012 by about 2.7-fold. Aging, male sex, transfusion, and obesity significantly increased the risk.

    View details for DOI 10.1097/ALN.0000000000001211

    View details for PubMedID 27362870

  • The Pupillary Light Reflex in Idiopathic Intracranial Hypertension INVESTIGATIVE OPHTHALMOLOGY & VISUAL SCIENCE Park, J. C., Moss, H. E., McAnany, J. J. 2016; 57 (1): 23-29

    Abstract

    To evaluate the effects of idiopathic intracranial hypertension (IIH) on rod-, cone-, and melanopsin-mediated pupillary light reflexes (PLRs).Pupillary light reflexes elicited by full-field, brief-flash stimuli were recorded in 13 IIH patients and 13 normal controls. Subjects were dark-adapted for 10 minutes and the PLR was recorded in response to short-wavelength flashes (0.001 cd/m2: rod condition; 450 cd/m2: melanopsin condition). Subjects were then exposed to a rod-suppressing field and 10 cd/m2 long-wavelength flashes were presented (cone condition). Pupillary light reflexes were quantified as the maximum transient constriction (rod and cone conditions) and the post-illumination pupil constriction (melanopsin condition), relative to the baseline pupil size. Diagnostic power was evaluated using receiver operating characteristic (ROC) analysis.The IIH patients had significantly smaller PLRs under the melanopsin (P < 0.001) and rod (P = 0.04) paradigms; a trend for reduced cone-mediated PLRs was also found (P = 0.08). Receiver operating characteristic analysis indicated areas under the curves (AUC) of 0.83 (melanopsin-meditated; P = 0.001), 0.71 (rod-mediated; P = 0.07), and 0.77 (cone-mediated; P = 0.02). The AUC (0.90, P < 0.001), sensitivity (85%), and specificity (85%) were high for ROC analysis performed on the mean of the rod, cone, and melanopsin PLRs.Pupillary light reflex reductions in IIH patients indicate compromised RGC function. PLR measurement, particularly under rod- and melanopsin-mediated conditions, may be a useful adjunct to standard clinical measures of visual function in IIH.

    View details for DOI 10.1167/iovs.15-18181

    View details for Web of Science ID 000373589500004

    View details for PubMedID 26746015

  • Retinal Vascular Changes are a Marker for Cerebral Vascular Diseases CURRENT NEUROLOGY AND NEUROSCIENCE REPORTS Moss, H. E. 2015; 15 (7)

    Abstract

    The retinal circulation is a potential marker of cerebral vascular disease because it shares origin and drainage with the intracranial circulation and because it can be directly visualized using ophthalmoscopy. Cross-sectional and cohort studies have demonstrated associations between chronic retinal and cerebral vascular disease, acute retinal and cerebral vascular disease, and chronic retinal vascular disease and acute cerebral vascular disease. In particular, certain qualitative features of retinopathy, retinal artery occlusion, and increased retinal vein caliber are associated with concurrent and future cerebrovascular events. These associations persist after accounting for confounding variables known to be disease-causing in both circulations, which supports the potential use of retinal vasculature findings to stratify individuals with regards to cerebral vascular disease risk.

    View details for DOI 10.1007/s11910-015-0561-1

    View details for Web of Science ID 000356253200003

    View details for PubMedID 26008809

  • The Photopic Negative Response in Idiopathic Intracranial Hypertension INVESTIGATIVE OPHTHALMOLOGY & VISUAL SCIENCE Moss, H. E., Park, J. C., McAnany, J. J. 2015; 56 (6): 3709-3714

    Abstract

    To evaluate the photopic negative response (PhNR) as an index of retinal ganglion cell (RGC) function in idiopathic intracranial hypertension (IIH).Amplitude and implicit time of the PhNR, as elicited by full-field, brief-luminance flashes, was measured in IIH (n = 10) and visually normal control (n = 15) subjects. Visual function was assessed in IIH subjects using standard automated perimetry mean deviation (SAP-MD) scores. Optic nerve structure was evaluated using the Frisén papilledema grading scale (FPG). Macula ganglion cell complex volume (GCCV) was extracted from optical coherence tomography images to assess RGC loss.Median PhNR amplitude was significantly lower in IIH subjects compared with control subjects (P = 0.015, Mann-Whitney Rank Sum [MW]), but implicit time was similar (P = 0.54, MW). In IIH subjects, PhNR amplitude and SAP-MD were correlated (Pearson's r = 0.78, P = 0.008). Ganglion cell complex volume was correlated with both SAP-MD (r = 0.72, P = 0.019) and PhNR amplitude (r = 0.77, P = 0.009). Multivariate linear regression models demonstrated that the correlation between GCCV and PhNR amplitude was improved by accounting for FPG in the model (r = 0.94, P < 0.0001), but the correlation between GCCV and SAP-MD was not (r = 0.74, P = 0.009).Photopic negative response amplitude, which can be decreased in IIH subjects, correlates well with a clinical measure of visual function (SAP-MD). In multivariate models, it correlated with both an imaging measure of chronic ganglion cell injury (GCCV) and a clinical measure of acute optic nerve head pathology (FPG). Further studies are needed to determine the clinical utility of PhNR as a marker for diagnosis and monitoring of IIH.

    View details for DOI 10.1167/iovs.15-16586

    View details for Web of Science ID 000357740200030

    View details for PubMedID 26047172

  • Retinal Vessel Diameter Assessment in Papilledema by Semi-Automated Analysis of SLO Images: Feasibility and Reliability INVESTIGATIVE OPHTHALMOLOGY & VISUAL SCIENCE Moss, H. E., Treadwell, G., Wanek, J., Deleon, S., Shahidi, M. 2014; 55 (4): 2049-2054

    Abstract

    To report feasibility and reliability of a semi-automated image analysis method for retinal vessel diameter measurements in subjects with papilledema before and after treatment.Scanning laser ophthalmoscopy (SLO) was performed in seven normal, five pseudopapilledema, and seven papilledema subjects. In four papilledema subjects, SLO was performed both before and following treatment. Two observers measured diameters of superior and inferior retinal arteries and veins from SLO images using two methods: manual analysis and semi-automated customized analysis. Vessel measurements were compared between observers and between image analysis methods. Retinal vein and artery diameters for each subject were compared between papilledema, pseudopapilledema, and normal subjects, and before and following treatment for papilledema subjects.Interobserver reliability was 0.97 (Pearson's correlation, r) and 0.90 for semi-automated and manual measurements, respectively. Correlation coefficient of manual and semi-automated measurements was 0.85. Retinal vein diameter in papilledema subjects was larger than in pseudopapilledema and normal subjects (P = 0.03, 0.04, Mann-Whitney). Papilledema subjects had a decrease in retinal vein diameter following treatment for and resolution of papilledema (P = 0.04, Wilcoxon signed rank). Retinal artery diameters were not significantly different between papilledema and pseudopapilledema or normal groups, and did not significantly change following papilledema treatment.A feasible and reliable semi-automated image analysis method for measurement of retinal artery and vein diameters from SLO images of elevated optic nerves is reported. Further studies are needed to determine the clinical utility of retinal vein diameter measurements as a marker for diagnosis and treatment of papilledema.

    View details for DOI 10.1167/iovs.13-13621

    View details for Web of Science ID 000335913100005

    View details for PubMedID 24609623

  • Association of Race/Ethnicity With Visual Outcomes Following Acute Optic Neuritis An Analysis of the Optic Neuritis Treatment Trial JAMA OPHTHALMOLOGY Moss, H. E., Gao, W., Balcer, L. J., Joslin, C. E. 2014; 132 (4): 421-427

    Abstract

    IMPORTANCE Retrospective studies have demonstrated disparate outcomes following acute optic neuritis in individuals of African descent compared with individuals of white race/ethnicity. However, published analyses of the prospectively collected Optic Neuritis Treatment Trial (ONTT) data identified no association between worse visual outcomes and black race/ethnicity. OBJECTIVES To investigate the associations of age, sex, and race/ethnicity with visual outcomes following acute optic neuritis through application of longitudinal data analysis techniques to the ONTT data set. DESIGN Secondary analysis of the ONTT (a prospective randomized controlled trial) data set. Our models included effects of treatment (placebo, oral prednisone, or intravenous methylprednisolone), time, and treatment × time interaction, as well as demographic covariates of age, sex, and race/ethnicity. SETTING AND PARTICIPANTS The ONTT data were collected at multiple centers in the United States. Patients of black (n = 58) and white (n = 388) race/ethnicity with acute optic neuritis who enrolled in the ONTT within 8 days of symptom onset were included in analyses. MAIN OUTCOMES AND MEASURES The contrast sensitivity and visual acuity (logMAR) in the affected eye were modeled using 2-stage mixed-effects regression techniques. All available follow-up data from baseline to 15 to 18 years were included. RESULTS The data identified no relationship of age, sex, or treatment with contrast sensitivity or visual acuity outcomes. Race/ethnicity was significantly related to contrast sensitivity (P < .001) and visual acuity (P < .001) during a 15-year period following acute optic neuritis, with black race/ethnicity being associated with worse scores for both. CONCLUSIONS AND RELEVANCE Race/ethnicity seems to be associated with contrast sensitivity and visual acuity outcomes in affected eyes following acute optic neuritis. To our knowledge, this is the largest cohort of black race/ethnicity with acute optic neuritis to be studied and represents the first evidence from a prospectively collected data set to support a hypothesis of race/ethnicity-dependent visual outcomes of acute optic neuritis.

    View details for DOI 10.1001/jamaophthalmol.2013.7995

    View details for Web of Science ID 000337890500008

    View details for PubMedID 24557028

  • Research Registries: A Tool to Advance Understanding of Rare Neuro-Ophthalmic Diseases. Journal of neuro-ophthalmology Blankshain, K. D., Moss, H. E. 2016; 36 (3): 317-323

    Abstract

    Medical research registries (MRR) are organized systems used to collect, store, and analyze patient information. They are important tools for medical research with particular application to the study of rare diseases, including those seen in neuro-ophthalmic practice.Evidence for this review was gathered from the writers' experiences creating a comprehensive neuro-ophthalmology registry and review of the literature.MRR are typically observational and prospective databases of de-identified patient information. The structure is flexible and can accommodate a focus on specific diseases or treatments, surveillance of patient populations, physician quality improvement, or recruitment for future studies. They are particularly useful for the study of rare diseases. They can be integrated into the hierarchy of medical research at many levels provided their construction is well organized and they have several key characteristics including an easily manipulated database, comprehensive information on carefully selected patients, and comply with human subjects regulations. MRR pertinent to neuro-ophthalmology include the University of Illinois at Chicago neuro-ophthalmology registry, Susac Syndrome Registry, Intracranial Hypertension Registry, and larger-scale patient outcome registries being developed by professional societies.MRR have a variety of forms and applications. With careful planning and clear goals, they are flexible and powerful research tools that can support multiple different study designs, and this can provide the potential to advance understanding and care of neuro-ophthalmic diseases.

    View details for DOI 10.1097/WNO.0000000000000391

    View details for PubMedID 27389624

  • Detection of retinal blood vessel changes in multiple sclerosis with optical coherence tomography BIOMEDICAL OPTICS EXPRESS Bhaduri, B., Nolan, R. M., Shelton, R. L., Pilutti, L. A., Motl, R. W., Moss, H. E., Pula, J. H., Boppart, S. A. 2016; 7 (6): 2321-2330

    Abstract

    Although retinal vasculitis is common in multiple sclerosis (MS), it is not known if MS is associated with quantitative abnormalities in retinal blood vessels (BVs). Optical coherence tomography (OCT) is suitable for examining the integrity of the anterior visual pathways in MS. In this paper we have compared the size and number of retinal blood vessels in patients with MS, with and without a history of optic neuritis (ON), and control subjects from the cross-sectional retinal images from OCT. Blood vessel diameter (BVD), blood vessel number (BVN), and retinal nerve fiber layer thickness (RNFLT) were extracted from OCT images collected from around the optic nerves of 129 eyes (24 control, 24 MS + ON, 81 MS-ON) of 71 subjects. Associations between blood vessel metrics, MS diagnosis, MS disability, ON, and RNFLT were evaluated using generalized estimating equation (GEE) models. MS eyes had a lower total BVD and BVN than control eyes. The effect was more pronounced with increased MS disability, and persisted in multivariate models adjusting for RNFLT and ON history. Twenty-nine percent (29%) of MS subjects had fewer retinal blood vessels than all control subjects. MS diagnosis, disability, and ON history were not associated with average blood vessel size. The relationship between MS and lower total BVD/BVN is not accounted for by RNFLT or ON. Further study is needed to determine the relationship between OCT blood vessel metrics and qualitative retinal blood vessel abnormalities in MS.

    View details for DOI 10.1364/BOE.7.002321

    View details for Web of Science ID 000377514000021

    View details for PubMedID 27375947

  • Bariatric Surgery and the Neuro-Ophthalmologist JOURNAL OF NEURO-OPHTHALMOLOGY Moss, H. E. 2016; 36 (1): 78-84

    Abstract

    As the prevalence of obesity increases, so, too, do the prevalences of weight-related diseases and surgical procedures to promote weight loss. It is important for neuro-ophthalmologists to be familiar with these procedures and possible downstream effects on afferent and efferent visual function.Review of ophthalmology, neurology, general surgery, obesity, endocrinology, nutrition, psychiatry, and neurosurgery literature.Bariatric surgery is a safe and effective treatment for weight loss in obese individuals. There is Level IV evidence that it is associated with improvement in idiopathic intracranial hypertension (IIH). Laboratory nutrient deficiencies are common following some types of bariatric procedures. Symptomatic deficiencies are less common but can be devastating. Thiamine deficiency can cause nystagmus and other symptoms in weeks to months after surgery, whereas B12 or copper deficiency can cause optic neuropathy in years to decades following bariatric surgery.Bariatric surgery is a potential treatment for IIH. Postoperative vitamin deficiencies may cause nystagmus, optic neuropathy, nyctalopia, and/or ophthalmoparesis weeks to years after surgery.

    View details for DOI 10.1097/WNO.0000000000000332

    View details for Web of Science ID 000371534000019

    View details for PubMedID 26764529

  • High and Low Contrast Visual Acuity Are Not Affected in Amyotrophic Lateral Sclerosis. PloS one Moss, H. E., Samelson, M., Mohan, G., Jiang, Q. L. 2016; 11 (12): e0168714

    Abstract

    The afferent visual system may be affected by neuro-degeneration in amyotrophic lateral sclerosis (ALS) based on observations of visual function impairment and retinal inclusions on histopathology in ALS patients. To test the hypothesis that visual acuity is impaired in ALS, we compared three measures of visual acuity in ALS patients (n = 25) attending a multidisciplinary ALS clinic and age matched control subjects (n = 25). Bilateral monocular and binocular visual acuities were assessed using high contrast (black letters on white background) and low contrast (2.5%, 1.25% grey letters on white background) visual acuity charts under controlled lighting conditions following refraction. Binocular summation was calculated as the difference between binocular and best monocular acuity scores. There were no associations between binocular or monocular high contrast visual acuity or low contrast visual acuity and amyotrophic lateral sclerosis diagnosis (generalized estimating equation models accounting for age). Binocular summation was similar in both amyotrophic lateral sclerosis and control subjects. There was a small magnitude association between increased duration of ALS symptoms and reduced 1.25% low contrast visual acuity. This study does not confirm prior observations of impaired visual acuity in patients with amyotrophic lateral sclerosis and does not support this particular measure of visual function for use in broad scale assessment of visual pathway involvement in ALS patients.

    View details for DOI 10.1371/journal.pone.0168714

    View details for PubMedID 28033389

  • Cross-Sectional Analysis of Neurocognitive Function, Retinopathy, and Retinal Thinning by Spectral-Domain Optical Coherence Tomography in Sickle Cell Patients. Middle East African journal of ophthalmology Oltra, E. Z., Chow, C. C., Wubben, T., Lim, J. I., Chau, F. Y., Moss, H. E. 2016; 23 (1): 79-83

    Abstract

    The purpose was to examine the relationship between neurocognitive function and two distinct forms of retinopathy in sickle cell disease.Patients with sickle cell disease (n = 44, age range: 19-56 years, 70% female) were prospectively recruited for this cross-sectional study. Retinopathy was characterized by: (1) Presence of focal retinal thinning on spectral domain optical coherence tomography and (2) determination of the sickle retinopathy stage on funduscopic exam based on Goldberg classification. Neurocognitive function was assessed using the Philadelphia Brief Assessment of Cognition (PBAC), a validated test of cognition. Univariate and multivariate analyses for PBAC score outcomes were performed. Retinal thinning and retinopathy stage were primary variables of interest and age, gender, genotype, education, and history of stroke were covariates.Univariate analysis revealed associations with total PBAC score and age (P = 0.049), history of stroke (P = 0.04), and genotype (P < 0.001). Focal retinal thinning and Goldberg retinopathy stage were not associated with each other in this sample. Neither the presence of focal retinal thinning nor degree of retinopathy was associated with total PBAC score in univariate or multivariate analyses.We find an association between lower cognitive function and older age, history of stroke and sickle cell genotype SS in patients with sickle cell disease. Our data do not provide evidence to support an association between cognitive function and retinopathy in sickle cell patients.

    View details for DOI 10.4103/0974-9233.150632

    View details for PubMedID 26957844

  • Isolated third, fourth, and sixth cranial nerve palsies from presumed microvascular versus other causes: a prospective study. Ophthalmology Tamhankar, M. A., Biousse, V., Ying, G., Prasad, S., Subramanian, P. S., Lee, M. S., Eggenberger, E., Moss, H. E., Pineles, S., Bennett, J., Osborne, B., Volpe, N. J., Liu, G. T., Bruce, B. B., Newman, N. J., Galetta, S. L., Balcer, L. J. 2013; 120 (11): 2264-2269

    Abstract

    To estimate the proportion of patients presenting with isolated third, fourth, or sixth cranial nerve palsy of presumed microvascular origin versus other causes.Prospective, multicenter, observational case series.A total of 109 patients aged 50 years or older with acute isolated ocular motor nerve palsy.Magnetic resonance imaging (MRI) of the brain.Causes of acute isolated ocular motor nerve palsy (presumed microvascular or other) as determined with early MRI and clinical assessment.Among 109 patients enrolled in the study, 22 had cranial nerve III palsy, 25 had cranial nerve IV palsy, and 62 had cranial nerve VI palsy. A cause other than presumed microvascular ischemia was identified in 18 patients (16.5%; 95% confidence interval, 10.7-24.6). The presence of 1 or more vasculopathic risk factors (diabetes, hypertension, hypercholesterolemia, coronary artery disease, myocardial infarction, stroke, and smoking) was significantly associated with a presumed microvascular cause (P = 0.003, Fisher exact test). Vasculopathic risk factors were also present in 61% of patients (11/18) with other causes. In the group of patients who had vasculopathic risk factors only, with no other significant medical condition, 10% of patients (8/80) were found to have other causes, including midbrain infarction, neoplasms, inflammation, pituitary apoplexy, and giant cell arteritis (GCA). By excluding patients with third cranial nerve palsies and those with GCA, the incidence of other causes for isolated fourth and sixth cranial nerve palsies was 4.7% (3/64).In our series of patients with acute isolated ocular motor nerve palsies, a substantial proportion of patients had other causes, including neoplasm, GCA, and brain stem infarction. Brain MRI and laboratory workup have a role in the initial evaluation of older patients with isolated acute ocular motor nerve palsies regardless of whether vascular risk factors are present.

    View details for DOI 10.1016/j.ophtha.2013.04.009

    View details for PubMedID 23747163

  • Cross-sectional evaluation of clinical neuro-ophthalmic abnormalities in an amyotrophic lateral sclerosis population JOURNAL OF THE NEUROLOGICAL SCIENCES Moss, H. E., McCluskey, L., Elman, L., Hoskins, K., Talman, L., Grossman, M., Balcer, L. J., Galetta, S. L., Liu, G. T. 2012; 314 (1-2): 97-101

    Abstract

    Ocular motility abnormalities may be a marker of neuro-degeneration beyond motor neurons in amyotrophic lateral sclerosis (ALS). We formally compared clinical neuro-ophthalmic abnormalities in ALS patients and a control population.Patients attending a multidisciplinary ALS clinic (n=63, age 60.8+/-16.4 years) and their caregivers serving as controls (n=37, ages 55.0+/-12.7 years) participated in this cross-sectional study. Visual acuity was assessed. Video recordings of a standardized ocular motility exam including gaze fixation, voluntary saccades, reflex saccades, smooth pursuit, eyelid opening and Bell's phenomenon were rated by two senior neuro-ophthalmologists who were masked to subject group.Visual acuity was lower in ALS patients versus control subjects (OR 0.81 (0.71-0.93), p=0.003, logistic regression). Inter- and intra-rater reliability for ocular motility examination ratings were good (Cohen's Kappa>0.6). Findings observed only in ALS subjects included gaze impersistence (14%, p=0.01), moderately or severely restricted voluntary upgaze (13%, p=0.01), and moderate or severe eyelid opening apraxia (27%, p=0.0002). Accounting for age, moderately or severely saccadic horizontal smooth pursuits distinguished ALS from control subjects (OR 3.6 (1.2-10.9), p=0.02, logistic regression).Clinical findings of decreased visual acuity, gaze impersistence, voluntary upgaze restriction, eyelid opening apraxia, and saccadic horizontal smooth pursuits are more frequent in patients with ALS than in similar-aged controls. These findings are potential clinical markers of neurodegeneration beyond upper and lower motor neuron disease in ALS. Further study is warranted regarding their application to disease categorization and outcomes assessment.

    View details for DOI 10.1016/j.jns.2011.10.016

    View details for Web of Science ID 000301273000018

    View details for PubMedID 22192877

  • Visual and Systemic Outcomes in Pediatric Ocular Myasthenia Gravis AMERICAN JOURNAL OF OPHTHALMOLOGY Pineles, S. L., Avery, R. A., Moss, H. E., Finkel, R., Blinman, T., Kaiser, L., Liu, G. T. 2010; 150 (4): 453-459

    Abstract

    To evaluate visual and systemic outcomes in pediatric patients with purely ocular myasthenia gravis (OMG) treated at the Children's Hospital of Philadelphia.Retrospective chart review.Pediatric patients with OMG seen at a single institution over a 16-year period with a minimum follow-up of 1 year were reviewed. Associations of demographic and clinical characteristics with disease resolution, amblyopia, and development of generalized symptoms of myasthenia gravis were analyzed.Thirty-nine patients were identified, with a mean age of 5.4 ± 4.8 years and mean follow-up of 4.8 ± 4.3 years. Fifteen patients were treated with pyridostigmine only, 19 (49%) also received steroids, and 15 (38%) underwent thymectomy. Four patients (10%) received steroid-sparing immunosuppressive therapy. Resolution occurred in 10 patients, and generalized symptoms eventually occurred in 9 patients. Although 10 patients were treated for amblyopia, only 1 had amblyopia at the final visit. There was no correlation between sex or age with amblyopia or development of generalized symptoms. Thymectomy, when performed before the onset of generalized symptoms, showed a trend toward protection from the development of generalized symptoms (P = .07).In our series, 24% of patients had disease resolution and 23% had generalized symptoms. Our larger cohort confirms previous findings that treated and untreated pediatric patients with OMG have a relatively low risk of developing generalized symptoms and that related amblyopia is readily reversible. Although our treatments were more aggressive than those previously reported, our rates of amblyopia and development of generalized symptoms are comparable.

    View details for DOI 10.1016/j.ajo.2010.05.002

    View details for Web of Science ID 000282867500003

    View details for PubMedID 20678749

  • Noninvasive Measurement of Cerebral Blood Flow and Blood Oxygenation Using Near-Infrared and Diffuse Correlation Spectroscopies in Critically Brain-Injured Adults NEUROCRITICAL CARE Kim, M. N., Durduran, T., Frangos, S., Edlow, B. L., Buckley, E. M., Moss, H. E., Zhou, C., Yu, G., Choe, R., Maloney-Wilensky, E., Wolf, R. L., Grady, M. S., Greenberg, J. H., Levine, J. M., Yodh, A. G., Detre, J. A., Kofke, W. A. 2010; 12 (2): 173-180

    Abstract

    This study assesses the utility of a hybrid optical instrument for noninvasive transcranial monitoring in the neurointensive care unit. The instrument is based on diffuse correlation spectroscopy (DCS) for measurement of cerebral blood flow (CBF), and near-infrared spectroscopy (NIRS) for measurement of oxy- and deoxy-hemoglobin concentration. DCS/NIRS measurements of CBF and oxygenation from frontal lobes are compared with concurrent xenon-enhanced computed tomography (XeCT) in patients during induced blood pressure changes and carbon dioxide arterial partial pressure variation.Seven neurocritical care patients were included in the study. Relative CBF measured by DCS (rCBF(DCS)), and changes in oxy-hemoglobin (DeltaHbO(2)), deoxy-hemoglobin (DeltaHb), and total hemoglobin concentration (DeltaTHC), measured by NIRS, were continuously monitored throughout XeCT during a baseline scan and a scan after intervention. CBF from XeCT regions-of-interest (ROIs) under the optical probes were used to calculate relative XeCT CBF (rCBF(XeCT)) and were then compared to rCBF(DCS). Spearman's rank coefficients were employed to test for associations between rCBF(DCS) and rCBF(XeCT), as well as between rCBF from both modalities and NIRS parameters.rCBF(DCS) and rCBF(XeCT) showed good correlation (r (s) = 0.73, P = 0.010) across the patient cohort. Moderate correlations between rCBF(DCS) and DeltaHbO(2)/DeltaTHC were also observed. Both NIRS and DCS distinguished the effects of xenon inhalation on CBF, which varied among the patients.DCS measurements of CBF and NIRS measurements of tissue blood oxygenation were successfully obtained in neurocritical care patients. The potential for DCS to provide continuous, noninvasive bedside monitoring for the purpose of CBF management and individualized care is demonstrated.

    View details for DOI 10.1007/s12028-009-9305-x

    View details for Web of Science ID 000275905800006

    View details for PubMedID 19908166

  • Anti-N-Methyl-D-Aspartate Receptor (NMDAR) Encephalitis in Children and Adolescents ANNALS OF NEUROLOGY Florance, N. R., Davis, R. L., Lam, C., Szperka, C., Zhou, L., Ahmad, S., Campen, C. J., Moss, H., Peter, N., Gleichman, A. J., Glaser, C. A., Lynch, D. R., Rosenfeld, M. R., Dalmau, J. 2009; 66 (1): 11-18

    Abstract

    To report the clinical features of anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis in patients < or = 18 years old.Information was obtained by the authors or referring physicians. Antibodies were determined by immunocytochemistry and enzyme-linked immunosorbent assay (ELISA) using HEK293 cells ectopically expressing NR1.Over an 8-month period, 81 patients (12 male) with anti-NMDAR encephalitis were identified. Thirty-two (40%) were < or =18 years old (youngest 23 months, median 14 years); 6 were male. The frequency of ovarian teratomas was 56% in women >18 years old, 31% in girls < or =18 years old (p = 0.05), and 9% in girls < or =14 years old (p = 0.008). None of the male patients had tumors. Of 32 patients < or =18 years old, 87.5% presented with behavioral or personality change, sometimes associated with seizures and frequent sleep dysfunction; 9.5% with dyskinesias or dystonia; and 3% with speech reduction. On admission, 53% had severe speech deficits. Eventually, 77% developed seizures, 84% stereotyped movements, 86% autonomic instability, and 23% hypoventilation. Responses to immunotherapy were slow and variable. Overall, 74% had full or substantial recovery after immunotherapy or tumor removal. Neurological relapses occurred in 25%. At the last follow-up, full recovery occurred more frequently in patients who had a teratoma that was removed (5/8) than in those without a teratoma (4/23; p = 0.03).Anti-NMDAR encephalitis is increasingly recognized in children, comprising 40% of all cases. Younger patients are less likely to have tumors. Behavioral and speech problems, seizures, and abnormal movements are common early symptoms. The phenotype resembles that of the adults, although dysautonomia and hypoventilation are less frequent or severe in children. Ann Neurol 2009;66:11-18.

    View details for DOI 10.1002/ana.21756

    View details for Web of Science ID 000268847600006

    View details for PubMedID 19670433