In medical school, Mark Breazzano encountered one of the big challenges inherent in preserving donor eyes: “You’re trying to cut through the eye, yet maintain the integrity of the anatomy,” says Breazzano, who kept thinking there had to be a better way. Then he remembered the Hoberman sphere — a favorite toy from childhood — and wondered if its structural concept might be applied in some way to allow for even distribution of pressure on an eye during cutting.
He reached out to a friend, a mechanical engineer and materials physicist, and together they collaborated on a device based on the Hoberman sphere that did just that. “Basically you open it up, put the eyeball inside, close it down and then have a knife go across the top of it while it distributes pressure evenly,” says Breazzano. “You can get a nice clean cut and minimize any disruption of the integrity.” The pair went on to patent their device.
It is this kind of innovative thinking that Breazzano brings to his new position as assistant professor of ophthalmology at the Wilmer Eye Institute. A retinal surgeon, he has a particular interest in endogenous Candida endophthalmitis (ECE), an infection inside the eye resulting from spread of the fungus Candida through the blood. In advanced stages, ECE can lead to loss of vision and even loss of an eye. Treatment is typically invasive, involving medication delivered intravitreally, with or without surgery to debride the vitreous “jelly” part of the eye.
Based on early studies, infection rates of ECE have historically been thought to be as high as 30%, In fact, Breazzano says, one of the most common hospital consults performed by ophthalmologists, particularly residents, involves screening for Candida. But as a resident at Vanderbilt University Medical Center and continuing as a fellow at New York-Presbyterian/Columbia University Medical Center, Breazzano led a large, systematic review that revealed the incidence is actually quite low. Moreover, the study found that any sign of the infection usually resolves with noninvasive, systemic treatment. The study was published in JAMA Ophthalmology last year.
Breazzano’s interest in ECE extends beyond issues of screening to researching effective treatments for advanced cases that require surgical intervention. A recent finding based on OCT imaging of Candida endophthalmitis lesions in the retina supports prior autopsy evidence that Candida actually originates in the choroid, in the very back part of the eye — outside the blood-outer retinal barrier. The implication, says Breazzano, who recently commented on the finding in a paper in BMC Ophthalmology, is that drugs used to treat the condition can penetrate into the focus of where the disease originates, without the need for invasive intervention. “We’re refining the imaging of endophthalmitis, as well as the true efficacy of medical intervention,” he says. “We’re minimizing when we need to do invasive intervention, yet still have optimal outcomes.”
The blood-outer retinal barrier and choroid feature prominently in another study, recently published in Ophthalmology Retina, in which Breazzano and colleagues used Viagra to improve vision in a small sample of patients with central serous chorioretinopathy, a relatively common, sight-stealing condition of the retina. “Viagra obviously increases blood flow, not only for erectile dysfunction but also pulmonary hypertension, and there is evidence that it increases blood flow within the choroid as well,” he explains.
In that study, two patients had restoration of 20/20 vision and resolution of the characteristic fluid behind the retina. “While it’s still in the early stages of investigation, it’s very exciting, because there have been a number of investigated approaches for [treating] central serous and there really hasn’t been a great option yet,” says Breazzano, who hopes to develop a larger study that includes patients with earlier-stage disease.
He is also interested in exploring whether delays in routine screenings during the time of COVID-19 can shed light on the efficacy of a variety of screening practices. “It has created an opportunity to evaluate a lot of our processes in terms of routine screening, and to answer the question of whether it makes sense to look for a given condition or not. Were we intervening too much in certain things, or have we done enough?” Breazzano, who says such a study would have implications across medicine, is currently evaluating data that could inform screening policy for a variety of conditions, based on outcomes related to deferred or delayed screenings during the pandemic.
Breazzano is looking forward to many opportunities for research and collaboration at Wilmer, including exploring the use of FDA-approved materials to enhance instrumentation currently used to treat advanced cases of Candida endophthalmitis. “Wilmer is clearly one of the best places in the country, if not the world, to be performing medical research and practicing ophthalmology,” he says. “I’m extremely excited to be here.”