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November/December 2006

NOVEMBER 12, 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

Head of Google’s philanthropic arm says ophthalmology is uniquely poised to take advantage of the “new philanthropy”
He should know. As executive director of Google’s philanthropic arm and founder of the Seva Foundation, Lawrence Brilliant, MD, is the very embodiment of the new philanthropy. Google has given him an estimated $1 billion and asked him to apply his innovative vision to solve the largest of the world’s problems. Dr. Brilliant and Alfred Sommer, MD, who identified the role of vitamin A deficiency in childhood blindness, were featured speakers at today’s Opening Session at the Joint Meeting in Las Vegas.

Dr. Brilliant explained that the old philanthropy focuses simply on doling out grants. Old philanthropy builds the small clinic in a poor country. It may be noble work, but it’s not financially self-sustainable or scalable, and it tends to build dependency. New philanthropy thinks of its work as an investment. It applies market forces to maximize its investment, controls costs and closely monitors outcomes. Most importantly, it is scalable. “The new philanthropy asks: ‘Is it globally sustainable, is there an exit strategy for the donors, is it profitable, socially good and environmentally stable?’ It always asks before writing the check, ‘Will this change the world?’” Dr. Brilliant said. “It’s a great adventure to make the world better for our children and grandchildren.”  

So how does ophthalmology make its efforts in blindness prevention attractive to the new philanthropy? Dr. Brilliant has some advice: Focus on providing excellent service, keep costs down, watch margins, track outcomes, use automated patient and financial records, use the Web for diagnosis and think outside the box.

“Technology is not just lasers,” he said. “Aravind (Aravind Eye Care System in India) has mobile eye vans that diagnose, triage and provide transportation all in one.”
Ophthalmology will be able to take advantage of the new philanthropy, he said, because it is a profession that “has made prevention and international work a part of its DNA.”

Evidence of this DNA became immediately apparent after Dr. Brilliant told the audience that these ideas would be explained further at an International Forum immediately following the Opening Session—200 ophthalmologists got up and followed him to the forum, where they were treated to examples of the new philosophy in action today. They heard from Susan Lewallen, MD, who has helped build a clinic in Tanzania where she trains cataract surgeons who go out to villages to perform cataract surgery. They also heard from David Green, founder and executive director of Project Impact, a nonprofit organization dedicated to making medical technology and medical services accessible, affordable and financially self-sustaining. Mr. Green is one of the “adventure capitalists” Dr. Brilliant described in his presentation. Project Impact, through a collaboration with Aurolab, helped bring to mark et a novel, foldable IOL that costs only $10. “You (the ophthalmologist) can access the new philanthropy,” said Dr. Brilliant. “Paying patients can fund the growth of sustainable systems. We can give the right to sight for every person. The question is, ‘Who’s going to pay for it.’”

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Conductive keratoplasty appears a good alternative for post-LASIK patients
During Saturday’s Refractive Surgery Subspecialty Day program, Michael Gordon, MD, reported results from a prospective, multicenter clinical trial of conductive keratoplasty on emmetropic patients who underwent previous myopic LASIK. In this study 44 patients (44 eyes) with a mean age of 53 years, had CK with eight spots at the 8 mm optical zone in the nondominant eye to improve near vision. Mean years between LASIK and CK was 5.3 years. At three months postop, 88 percent had a near UCVA of J2 or better and 95 percent had J3 or better. At six months, 78 percent had near UCVA of J2 or better and 87 percent had J3 or better. In terms of predictability, 78 percent were within 0.5 D of target. No eye lost two or more lines of BCVA-distance. No eye had a BCVA-distance worse than 20/40 or had an increase of more than 2 D of cylinder. Also, 86 percent had 20/20 or better intermediate vision and all eyes had 20/32 or better. More importantly, this procedure made for very happy patients: 91 percent reported a significant or moderate improvement in vision, and 91 percent reported being very satisfied to satisfied with their vision. “This is a very appealing procedure for post-LASIK patients because of the safety and simplicity of the procedure,” Dr. Gordon said. “And because these patients are motivated to remain glasses free.”

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Wavefront-guided surface ablation with MMC can successfully salvage LASIK flap complications
Maria Regina Chalita, MD, reported on three patients whose surgery was aborted following complications of buttonhole or irregular flaps. She spoke during Saturday’s Refractive Surgery Subspecialty Day program. Three to four months later, all patients underwent wavefront-guided PRK with MMC. After the LASIK complication, all eyes lost at least one line of BCVA. After PRK, all eyes returned to their preoperative BCVA, and high-order aberrations were reduced in all cases. Dr. Chalita cautioned that epithelial removal should be gentle in order to avoid flap complications or epithelial ingrowth. No patient experienced delayed epithelial healing or side effects. No MMC-related complications were noted.

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Punching it out under pressure
Surprise! The question of how best to manage glaucoma progression was posed at the Saturday Glaucoma Subspecialty Day, and boxing gloves were passed around to several panelists.

The first round of collegial sparring began with Dale K. Heuer, MD, squaring off with Jody R. Piltz-Seymour, MD, on the question of whether surgery is indicated in the presence of glaucoma progression and a mean IOP of 10 mmHg. “Cut away!” was the answer from Dr. Heuer, who noted that if the standard deviation is considered, a mean pressure of 10 mmHg necessarily ignores the higher pressures within the deviation. In fact, he pointed out, peak pressures often occur outside office hours, thus eluding detection. He pointed to a study by Medeiros and colleagues that found that POAG patients on medication had pressure fluctuations greater than those who had trabecular surgery. Another study by Konstas and colleagues showed that surgery achieves lower pressures longer than medication. “Not so fast!” was Dr. Piltz-Seymour’s response, on the grounds that, in OHTS at least, 86 percent of visual field deficits are not confirmed on repeat testing, and there is a multitude of risk factors not addressed by surgery, such as autoimmunity, sleep apnea and systemic hypertension. In addition, there is little evidence that lowering IOP below 10 mmHg is useful. In any event, she added, medical management is far safer than surgery. In their final round, Dr. Heuer sang his rebuttal, and Dr. Piltz-Seymour delivered hers in rhyming verse.

The next exciting match pitted Richard Parrish, MD, against challenger Kuldev Singh, MD, on the question of whether selecting a target IOP is necessary for effective glaucoma management. Dr. Parrish took what might be considered the mainstream view: Virtually every study and anecdotal report shows that clinicians who choose a target pressure consistently arrive at lower pressures than those who do not. Wait just a minute, said Dr. Singh. Intraocular pressure has been dethroned as the sole criterion for glaucomatous damage, and the fabled pressure of 12 mmHg is just simply arbitrary when considered in the context of the many contributing factors for progression. Apparent disc changes may or may not be related to true visual loss, and what makes more sense is to target the range of pressure that each patient can tolerate without progressing, said Dr. Singh.

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