American Academy of Ophthalmology Web Site: www.aao.org
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November/December 2006

 
 
 

CLINICAL NEWS OF MONDAY,
NOVEMBER 13, 2006

Editor-in-Chief: H. Dunbar Hoskins Jr., MD
Chief Medical Editors: Richard P. Mills, MD, MPH and Andrew G. Iwach, MD
Executive Editor: Patty Ames | Managing Editor: Susanne Medeiros
Senior Editors: Denny Smithand Chris McDonagh
Advisory Panel:
Terry L. Forrest, MD, Jean E. Ramsey, MD, Franco M. Recchia, MD,
James C. Tsai, MD and Helen K. Wu, MD
Guest Medical Editor: Mark F. Torres, MD



Leading refractive surgeon takes the mystery out of multifocal IOLs
“Multifocal and accommodating lenses are dramatically changing the way all ophthalmologists practice cataract and refractive surgery,” said Eric D. Donnenfeld, MD, during “Monday’s Spotlight on Pseudophakic IOLs 2006: Where Are We Now? Where Are We Going?”

“All cataract surgery is becoming refractive surgery,” said Dr. Donnenfeld. He offered his own version of “Refractive IOLs for Dummies” to help the cataract surgeon make the transition. First you have to understand the mindset of the presbyopic refractive patient.  They are largely Baby Boomers who view diminished vision as a sign of aging that must be avoided at all costs. “These patients want to see better than they did before surgery, and not wear glasses as often,” he said. “These are the most challenging patients we face in our cataract and refractive practices.”

The physician’s mindset also needs to change. You are providing a true service to your patient, Dr. Donnenfeld explained. You have to increase your comfort with the new technology: read the literature on the new lenses, attend refractive IOL surgery courses and view a successful surgery practice to see for yourself how it’s done. You need an internal marketing program that includes everyone—schedulers, technicians, patient coordinators, etc.—so that by the time the patient reaches you they know about the procedure. Before surgery, you must obtain accurate biometric measurements. IOL Master or Immersion A-scan are essential. “You can’t perform this surgery without them. I can’t emphasize how important this is,” he said.

A lot of chair time with patients is also important before surgery. You need to manage their expectations. Tell them about distance blur, ghosting, halos at night and the possibility for enhancement surgery. When it comes to surgery, “Just do the excellent surgery you’ve always done,” he said. Make a small, clean incision, adjust astigmatism, make a centered 5.0 mm capsulorhexis, avoid capsular rupture and center the IOL on the visual axis.

Refractive cataract surgeons must be willing and able to treat postoperative refractive errors. He said that it’s a myth that presbyopic IOL patients will tolerate small refractive errors: They will not, he assured the audience. You must be willing to perform limbal relaxing incisions (LRIs) to manage astigmatism and to treat residual myopia or hyperopia with PRK. (He showed how LRIs can be made “ridiculously easy.” Using a diamond blade, he made incisions at the slit lamp, a 30-second procedure.) “Learn PRK. It’s less stressful than LASIK and you get good results.” You can also partner with an experienced refractive surgeon who can treat the residual refractive error. About 10 percent of multifocal IOL surgeries will require an excimer laser enhancement. “These are the most demanding and most challenging patients we face in our cataract and refractive p ractices,” Dr. Donnenfeld said. “But the successful presbyopic refractive patient with good outcomes whose expectations have been met is also the most grateful patient in our practice, and presents an enormous opportunity for all of us.”

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How do you know when it’s time to tell your glaucoma patients to give up driving?
“This is a more complicated question than one might realize,” said Cynthia Owsley, MSPH, PhD. First there are quality of life issues. “Losing the ability to drive is much more than a personal inconvenience, it’s also linked to depression and isolation. This question shouldn’t be taken lightly,” she said.

At the same time there are legal issues to consider. There are an increasing number of cases in which people injured in car crashes seek damages not only from the driver, but also from the driver’s physicians. Some states have laws mandating physicians to report drivers with medical conditions that could threaten safe driving. “There is no association between having glaucoma and an elevated risk for crash rates. But moderate to severe visual field loss in one eye statistically elevates the rate of crashing,” Dr. Owsley said. She said on-road driving performance studies show that moderate to severe visual field loss in the central 30 degrees in at least one eye (AGIS score of 12 or greater) in glaucoma patients does elevate crash risk.

What should the ophthalmologist do? “When they reach a moderate level of visual field loss, you need to begin a dialogue to discuss the importance of visual field loss,” Dr. Owsley said. Know your state’s laws with respect to visual field standards and visual acuity standards. Know if your state has a law mandating physician reporting of drivers who do not meet the standard or have any medical condition you believe threatens safety. For those who fall into a gray area, consider referring them to a driving rehabilitation specialist who has the appropriate professional training to determine driver fitness.

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Problem strabismus cases
Sunday’s Session on “Difficult Strabismus Problems,” offered a number of intriguing cases of gaze deviation caused by a wide variety of etiologies.

Arthur L. Rosenbaum, MD, shared the case of a 6-year-old boy whose parents had noticed a progressive left face turn. He did indeed exhibit right hypertropia on left gaze. Although he had a history of meningitis as a baby, his mother said she definitely noticed the strabismus before that. She also reported a family history of strabismus. Dr. Rosenbaum reported that the boy’s exotropia and right hypertropia increased in progressive left gaze and was reduced in right gaze. On attempted adduction of the right eye, the boy showed a narrowing of the palpebral fissure and some globe retraction. A diagnosis of Duane syndrome was made.

Burton J. Kushner, MD, described a 44-year-old mechanical engineer who had been injured in a motor vehicle accident. Bilateral superior oblique palsies were corrected by surgery such that the patient’s eyes were straight in primary position. But one year after surgery, he exhibited bilateral excyclotropia. Harada-Ito procedures corrected the torsion in primary position, but not completely in downgaze. Dr. Kushner performed bilateral nasal transpositions of the inferior rectus muscles, and found a resulting esotropia in distance and near vision, as well as 5 to 10 degrees of incyclotropia. The patient was unable to fuse with prisms due to the torsion. Dr. Kushner concluded by acknowledging the conflict between successfully correcting torsion with vertical rectus transposition while avoiding the induction of a horizontal deviation.

The course included a case offered by Henry Metz, MD, regarding a 43-year-old man with a recent history of proptosis in the left eye and horizontal diplopia. He also reported fatigue, anorexia and pain on his left side. Visual acuity was 20/20 OD and 20/25 OS. The left eye also demonstrated intermittent left exotropia but normal horizontal saccadic velocity. A medical workup found a palpable axillary lymph node on the patient’s left side, and a CT scan showed a diffuse, fusiform mass in his left orbit, with enlargement of the left medial rectus muscle. Pathology identified the biopsied node as melanoma.

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Tecnis multifocal IOL may provide slightly better near vision than the ReStor IOL
Manfred Tetz, MD, of the Berlin Eye Research Institute in Germany, on Monday presented results from a clinical study that included 28 patients (46 eyes) with a mean age of 60. “There was slightly better near vision with the Tecnis compared to the ReStor. This difference was confirmed in the difference in reading speed. “There was a somewhat increased reading speed with the Tecnis,” he said. Overall quality of vision was good, uncorrected distance vision was 20/25, and there were few problems with halo and glare.

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Blue light filtering IOLs are here to stay
Jim McCulley, MD, speaking during “Cataract Monday,” said many of the initial questions and concerns about blue light filtering IOLs have been answered. “It’s no longer a question of whether or not to use these IOLs, but which one to use,” he said.

These IOLs don’t affect color vision, night vision or glaucoma testing. These concerns have been put to rest, he said. The last unanswered question is the relationship between blue light filtering and AMD. “Does it (blue light toxicity) increase the risk for AMD? Absolutely not. Is it a factor? Probably.” If there is an effect, it’s not clinically important. “There is no certain link between blue light toxicity and retinal damage,” he said. Patients with these lenses also maintained good circadian rhythm and gained slightly improved contrast sensitivity.

Randall J. Olson, MD, agreed, “It appears likely from the AREDS study that the finding of increased macular degeneration in association with cataract surgery most likely represents pre-existing macular degeneration not noticed until after cataract surgery, rather than cataract surgery inducing macular degeneration through blue light toxicity. Cataract surgery may be protective against macular degeneration.” But Dr. Olson disagreed that these lenses pose no problems to patients’ circadian rhythms, as blue light IOLs may play a factor in insomnia. He cited studies that showed the loss of melanopsin production with blue light blocking is a clinically important effect. “I don’t think it has been ruled out,” Dr. Olson said. “There is evidence that it is clinically relevant.”

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Unique characteristics of ReNu with MoistureLoc responsible for recent outbreak of Fusarium keratitis
“It appears the overall strength of the disinfectant (in ReNu with MoistureLoc) may not be good enough to kill the organism,” said R. Doyle Stulting, MD, on Saturday during the Refractive Surgery Subspecialty Day meeting. Although the FDA determined the solution was safe and effective, clearly it was not, Dr. Stulting said.

Bausch & Lomb issued a worldwide recall of the product last spring. The problem is that the FDA tested the solution under ideal conditions, not under conditions of actual use. “When it was tested it was found to be safe and effective, but in use it was not safe and effective,” said Dr. Stulting. “The FDA’s study of multipurpose solutions may not be adequate to predict their performance under conditions of actual use,” he said.

Dr. Stulting collected the contact lens cases, lenses and solution containers from seven patients with confirmed or probable Fusarium keratitis referred to him last spring. Using transparent adhesive tape preparations and cultures, he determined the fungal colonization in and on these items. Dr. Stulting also tested the survival and growth rate of selected isolates of Fusarium species in the drying film of multipurpose solution (ReNu with MoistureLoc, ReNu Complete, ReNu Multi-Purpose and Opti-Free) on plastic surfaces.

He found that while the isolates were inhibited by fresh solution in original solution containers and contact lens cases, they survived in the drying films of multipurpose solution. Tenfold or more viable conidia were recovered from drying ReNu with MoistureLoc films than in the drying films of other products. Microscopy showed apparently viable fungi in entrapped globules of the partially dried waxy deposits of ReNu with MoistureLoc. “Residual drying film harbors Fusarium, it allows it to grow, survive, replicate and flourish,” Dr. Stulting explained. This film coated the surface of the lenses, the contact lens case and the outside of the bottles with a waxy deposit that was difficult to remove. In the absence of good contact lens cleaning and handling, the risk of contracting Fusarium keratitis increased. Dr. Stulting has informed the FDA of his findings about a w eek ago.

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Promising early results with the Tetraflex accommodative IOL
On Saturday, David C. Brown, MD, presented interim results of a trial at Refractive Surgery Subspecialty Day. Tetraflex is a posterior chamber poly-HEMA accommodating IOL with a 5.75-mm optic. After three months follow-up, 88 percent of 27 patients (27 eyes) could see 20/60 or better uncorrected at distance, and 94 percent could see 20/80 or better at near with distance correction. Patients didn’t complain of dysphotopsia, glare or halos, and 94 percent were reading newsprint. No intraoperative complications and no incidences of capsular contraction occurred.

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General medicine for ophthalmologists
Community ophthalmologists were given a chance to catch up on the latest thinking on a wide range of pathologies, from hypertension, heart disease and diabetes to immunizations and geriatric medicine in the “General Medicine Update for the Comprehensive Ophthalmologist: BCSC Section 1 Course.”

Eric P. Purdy, MD, chaired today’s medical session, and began with an
overview of the latest diagnostic tools and antimicrobial agents for
common infectious diseases. Polymerase chain reaction probes are providing
nearly fail-proof detection of more and more pathogens, including Neisseria gonorrhoeae, Chlamydia trachomatis, pathogenic Borrelia species and various mycobacteria and viruses. Amazingly, one multiplex PCR assay can detect Neisseria meningitidis, Haemophilus influenzae and Streptococcus pneumoniae simultaneously.

Dr. Purdy noted that drug-resistant staphylococcal infections have been a concern for a number of years now, and a new generation of antibiotics has risen to take the place of vancomycin, including linezolid, trovafloxacin, evernimicin, daptomycin and quinupristin/dalfopristin. Linezolid is also effective against many multidrug resistant infections of tuberculosis, and, in fact, may be the most potent new antibiotic tested against gram-positive cocci.

Progress in treating HIV infection has proceeded apace, with new combinations of antiretrovirals (ARVs) offering vastly more convenient dosing than the older multiple-agent regimens. All classes of ARVs have new members, including the nucleotide and non-nucleoside reverse transcriptase inhibitors, the protease and nonpeptidic protease inhibitors, and the fusion inhibitors. These great advances have allowed many patients to achieve an undetectable viral load, and have led to an 82 percent decline in the number of opportunistic infections diagnosed in patients on highly active antiretroviral therapy. Fortuitously, research into AIDS-related infections has yielded a plethora of drugs for hepatitis B and C, cytomegalovirus, herpes simplex and herpes zoster, human papillomavirus, and several mycobacterial infections. The relatively new antifungals fluconazole and itraconazole have largely replaced k etoconazole as the treatments of choice for infections like meningitis and candidiasis.

Hypertension is the elephant in America’s living room, and an overview by Harold E. Shaw, MD, helped attendees put this creature in perspective. He said that 65 million people in the United States, and one billion around the world, have elevated blood pressure. The potential for mortality and morbidity is daunting: myocardial infarction, peripheral vascular disease, stroke, kidney disease and, of course, retinal vascular disease. Since the prevalence of hypertension increases with age, and often parallels the incidence of diabetes, ophthalmologists will be seeing more and more patients with multisystem presentations. Hypertension today is defined as a systolic pressure greater than 140 mmHg and a diastolic pressure over 90 mmHg. But a new classification of “prehypertension” has been created for pressures below that but above normal, and that includes millions of unsuspecting Am ericans who are at risk for future disease. The interrelated etiologies of hypertension, are, fortunately, often controlled with the same behavior changes that diabetics are prescribed: diet and exercise. Otherwise, said Dr. Shaw, a number of therapies, especially diuretics, are highly effective at controlling most cases. He added that ophthalmic considerations in the uncontrolled hypertensive patient include retinopathy, retinal vascular occlusions, glaucoma, ischemic optic neuropathy and cranial nerve palsies.

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Hear the latest on the Retina Subspecialty Day meeting
The Academy has posted several podcasts from this week’s Retina program. Learn more about anti-VEGF treatment, diabetic retinopathy, vitreoretinal surgery, complications of AMD, imaging and more.

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Best Annual Meeting attendance ever
As of Sunday evening, attendance numbers for the Joint Meeting of the Academy and the Asia Pacific Academy of Ophthalmology were the highest in the history of the Academy at 26,400. Final attendance numbers for the Subspecialty Days were also at all-time highs: Glaucoma was 2,097, Refractive Surgery was 2,073 and Retina was 2,955. Please join us next year in New Orleans for Subspecialty Day, Nov. 9 to 10 and the Annual Meeting from Nov. 10 to 13.

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EyeNet provides you with all of the information you need to make the most out the Joint Meeting. Be sure to check out EyeNet's Joint Meeting Publications:

* EyeNet Selections:Glaucoma*, Retina* and Refractive Surgery*
* EyeNet's Guide to Academy Exhibitors
* EyeNet's November/December Issue
* EyeNet's Papers and Posters
* EyeNet's Academy News -
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