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Andrea Kossler, MD

  • Andrea L Kossler

Specialties

Ophthalmology

Work and Education

Professional Education

Georgetown University, Washington, DC, 2006

Internship

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

Residency

Bascom Palmer Eye Institute, Miami, FL, 2010

Fellowship

Bascom Palmer Eye Institute, Miami, FL, 2012

Board Certifications

Ophthalmology, American Board of Ophthalmology

Services

Eyes & Vision

All Publications

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

Abstract

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 Web of Science ID 000400649600047

View details for PubMedID 28431436

View details for PubMedCentralID PMC5398789

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

Abstract

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

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

Abstract

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

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. 2017: 194599817728896

View details for DOI 10.1177/0194599817728896

View details for PubMedID 28871877

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

Abstract

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

Abstract

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-?

Abstract

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

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

Abstract

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

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 2013

Abstract

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
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
Pediatric Cataract Ophthalmic Surgical Procedures Cremers, S., Lora-Kossler, A., Azar, N. edited by Hersh, P. S., Zagelbaum, B., Cremers, S. Thieme. 2009; 2nd
Systemic Multiple Myeloma with Secondary Orbital Plasmacytoma Ophthalmology Times Andrea, L. 2008
Conjunctival Squamous Cell Carcinoma with Intraocular and Intraorbital Invasion Ophthalmology Times Lora-Kossler, A., Johnson, T. 2008
Time Domain versus Spectral Domain Optical Coherence Tomography (OCT) in the Diagnosis and Treatment of Angioid Streaks Ophthalmology Web Lora-Kossler, A. 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

Abstract

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

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

Abstract

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