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Friday, October 15

Chicago welcomes thousands of eye surgeons today as the Academy’s Oculofacial Plastic Surgery, Refractive Surgery and Retina Subspecialty Day meetings commenced. Here are some highlights.



Time to rethink prophylactic antibiotics before intravitreal injections

In presenting an evidence-based review of common components of the intravitreal injection process, Jonathan L. Prenner, MD, made a strong case for reconsidering the routine use of prophylactic perioperative antibiotics. The dollar amount and the cost in terms of promoting antibiotic resistance may be too high.

The risk of post-injection endophthalmitis is rare, at about 0.05 percent. But with the large numbers of injections given each year, the threat of endophthalmitis is significant and rising. “We will give 3 million injections this year,” Dr. Prenner said. “Yet there is a surprising lack of consensus concerning practice patterns for intravitreal injections.”

The use of prophylactic antibiotics has minimal, if any, evidence-based support, he said. Endophthalmitis incidence in prospective trials of ranibizumab show the rate is similar whether or not peri-injection antibiotics were used. Still, practice surveys suggest that the majority of retina specialists use topical antibiotics before and/or after intravitreal injections.

The 2009 ASRS Preferences and Trends Survey (PAT) showed 39.4 percent of respondents use prophylactic topical antibiotic drops before intravitreal anti-VEGF injection and 82.48 percent use prophylactic topical antibiotic drops after an injection.

“Why are we using it? Intellectually it makes sense,” he said. “There’s a reluctance to change practice patterns that seem to be effective. The problem with this experience-based approach is that it is not applicable to rare events such as post-injection endophthalmitis.”

There is evidence that short courses of antibiotics may promote antibiotic resistance, he said. A recent study of acute onset endophthalmitis after cataract surgery found that 74 percent of patients had been treated with perioperative gatifloxacin or moxifloxacin, and 57 percent were continuously taking one of these at the time of diagnosis.

“There are real consequences in terms of resistance and costs,” Dr. Prenner said. “By the year 2020, we’ll have given 40 million injections and spent $1 billion in prophylactic topical antibiotics.”

Dr. Prenner also reviewed practice patterns regarding anesthesia for intravitreal injections. The main methods used according to the 2009 PAT survey are: topical nonviscous anesthetic drop (21.48 percent), topical viscous anesthetic drop (23.33 percent), topical anesthetic plus soaked cotton tip or pledget (29.79 percent) and subconjunctival anesthetic (24.02 percent).

Meta-analysis of numerous papers prospectively evaluating various techniques for anesthesia before injection found that the overall pain experience is similar for these four commonly employed techniques, he said. Therefore, the choice of anesthesia should be tailored to the patients’ needs.

Dr. Prenner provided an overview of the overall pain experience for all of these techniques:

  • Topical drop anesthetics have no pain associated with placement of medication, but they are associated with the highest injection-related pain levels. Viscous gels also carry the theoretical risk of increasing the rate of endophthalmitis.
  • Pledget delivery is associated with discomfort during the placement of the device and numbing process. The anesthetic effect tends to be superior to topical agents at the time of injection.
  • Subconjunctival lidocaine provides the best anesthesia for the actual injection. However, patients have discomfort during administration and frequently develop subconjunctival hemorrhage, which mutes the effectiveness of the subconjunctival technique in terms of overall pain experience.—Susanne Medeiros

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Accommodation by Synchrony IOL

Colombian ophthalmologists with seven years of experience implanting the Synchrony lens (Abbott Medical Optics) presented objective evidence Friday that this dual-optic accommodating intraocular lens (A-IOL) retains its refractive add power for at least four years.

Speaking at the Academy Subspecialty Day’s Refractive Surgery meeting sponsored by the International Society for Refractive Surgery (ISRS), Ivan L. Ossma-Gomez, MD, MPH, presented data on five eyes in which long-term subjective testing was augmented with two objective tests of accommodative effort:

  • High-resolution ultrasound biomicroscopy (UBM) at one and four years postop, to determine the positions of the anterior and posterior optics with and without a near stimulus.
  • Refractive difference maps from wavefront aberrometry (iTrace, AMO/Tracey Technologies). Aberrometry was done annually at two, three and four years postop.

With subjective push-down testing, distance-corrected near visual acuity (DCNVA) in the five eyes was stable through four years; DCNVA was 20/25 or better at all times, said Dr. Ossma-Gomez, who practices at Fundación Valle del Lili, in Cali, Colombia. Subjective accommodation was between 1.85 D and 2.83 D, he said.

The UBM imaging showed that forward axial movement of the anterior optic did not change significantly between the one-year and four-year exam. On the refractive maps, optical power increased by an average of 2.9 D during accommodation, and was stable over time.

Dr. Ossma-Gomez said that these objective tests demonstrate that, when Synchrony’s anterior optic shifts forward, the eye’s refractive power increases (“pseudophakic accommodation”).

The results “demonstrate the preservation of accommodative effect over time. This also has been shown in larger cohorts over the first seven years of follow-up,” he said.

Similar objective testing regimes have been used recently by other researchers to show that, with single-optic A-IOLs, such as the Crystalens and others in use in Europe, lens movement provides little, if any, of the 1.5 D to 2.0 D gains in near VA that have been reported previously. They suggest that postop improvements in near acuity instead represent pseudoaccommodation (i.e., wider depth of focus because of ocular factors like pupil constriction, astigmatism and spherical aberration).

Elaborating on the Synchrony results in an interview, Dr. Ossma-Gomez said he believes pseudophakic accommodation is the norm for this dual-optic lens, based on his clinical experience.

His group has implanted more than 500 Synchrony A-IOLs, of which 151 have been in place for more than four years and 49 for seven years. There have been no interlenticular opacities, and 3.3 percent of the lenses have required YAG capsulotomy for posterior capsular opacification, he added.

The Synchrony A-IOL already has the CE mark for use in Europe. In the United States, the FDA is considering the results of U.S. clinical trials, and it could issue an approval this year.—Linda Roach

Dr. Ossma-Gomez is a consultant for and receives grant support from AMO.

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Low incidence of endophthalmitis in gas-filled eyes after sutureless pars plana vitrectomy

The increasing usage of and indications for small-gauge vitrectomy have been associated with an increase in post-vitrectomy complications, including endophthalmitis, and multiple reports have suggested an increase in the incidence of endophthalmitis in fluid-filled eyes compared with air- or gas-filled eyes, noted Richard Kaiser, MD, during Retina Subspecialty Day.

To test the hypothesis that performing an air or gas exchange at the conclusion of a sutureless vitrectomy is beneficial, Dr. Kaiser decided to conduct a large retrospective analysis of macular hole cases, for which the standard technique is to perform a near-complete gas-fluid exchange during surgery. He examined the records of all consecutive patients who underwent 23-gauge pars plana vitrectomy for macular hole repair at a single center in 2008 and 2009, then shared his methodology with eight collaborating study participants who did the same at their respective institutions.

Of a total of 2,336 consecutive cases, only one (0.04 percent) had postoperative endophthalmitis after three months, which is beyond the expected time frame for development of acute postoperative endophthalmitis. In a previously published case series, Dr. Kaiser found all endophthalmitis cases (seven) to be fluid-filled.

Dr. Kaiser concluded that gas-filled eyes seem to have a lower incidence of endophthalmitis. “I’m not saying that this is what we should do in every case, but it’s something to think about in terms of sutureless vitrectomy.”—Mark Simborg

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ICLs in the Army

The Visian ICL (implantable collamer lens) not only gives young soldiers excellent visual acuity but also apparently does not subject their eyes to extra risks from traumatic injury, a U.S. Army refractive surgeon reported Friday at Refractive Surgery Subspecialty Day.

Col. Scott D. Barnes, MD, chief of the Fort Bragg (N.C.) Warfighter Refractive Surgery unit, presented results from a study of bilateral ICL implants in 100 myopic soldiers (mean –7.11 D; range –3 to –14 D). Eighty percent of the soldiers attained 20/15 vision, with minimal complications.

Previously, 96 percent of the 38,000 laser vision corrections at Fort Bragg were PRK, due to the risk for LASIK flap displacement in combat, he said. Early fears of added risks in ICL eyes from trauma subsided after two instances—an auto accident and a grenade injury in Iraq—in which ICL complications did not occur, he said.

Col. Barnes said that 750 soldiers now have received ICLs at Fort Bragg, and its popularity is increasing by word of mouth. It might be time, he said, to begin “looking at whether the ICL might be better than laser vision correction” for soldiers.—Linda Roach

Dr. Barnes receives lecture fees from Staar Surgical.

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Dr. Tasman gives 3rd annual Schepens lecture

Retinopathy of prematurity (ROP), first recognized 70 years ago, is still with us and it appears to be on the rise, said William Tasman, MD, a pediatric retina specialist, who presented the third annual Charles L. Schepens Lecture Friday morning at Retina Subspecialty Day. “We may be facing an epidemic of retinopathy of prematurity due to the survival of low birth weight babies,” Dr. Tasman said.

ROP, which Dr. Tasman called “a lifetime disease,” is on the rise in both industrialized and developing countries as we learn how to save a greater number of low birth weight, early term babies.

In the United States, the problem is growing due to the survival of extremely low birth weight babies—under 1,000 grams. Many are delivered at 23 weeks gestation. ROP may develop in 72 percent of babies under 1,000 grams. Up to 10 percent of those may become blind.

At the Overbrook School for the Blind, nearly 20 percent of the children between 3 and 5 years of age have ROP. Similarly, almost 17 percent of children at Perkins School in Massachusetts are afflicted. 

The problem is worldwide. In developing countries, larger, more mature infants—those born between 26.3 to 33.5 weeks gestation and weighing 903 to 1527 grams—are developing ROP.

While laser therapy is effective in 90 percent of cases, Dr. Tasman said “the big thing now” is anti-VEGF therapy with bevacizumab. The current dosage of Avastin is half the adult dosage, though the infant’s vitreous cavity is one-third the size of the adult’s, he said.

But Dr. Tasman urged caution when using anti-VEGF agents to treat ROP. He cited three exceptions: unsatisfactory response to laser, inability to dilate the pupil and persistent tunica.—Miriam Karmel

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Retina roundup

First came the revolution. The discovery that the anti-VEGF agents—bevacizumab and ranibizumab—effectively dried the eye, radically changing the course of treatment for wet AMD. Now come the questions. How many treatments are needed? What is the optimal dosing interval? Is there an effective adjunct that will minimize the need for re-treatment and optimize results? And what, oh what, do we do with the patients who don’t respond? 

These were among the questions taken up Friday at Retina Subspecialty Day, by speakers reporting on a number of studies, including several with jaunty sounding nautical names: MARINA, ANCHOR, PIER and SAILOR.

While the audience was encouraged to stay tuned for study results, there was a sense that ongoing and relatively frequent follow-up appears important. And while combination therapies hold promise, nothing has emerged at the head of the pack. 

Highlights:
Dosing. Individualized dosing on an as-needed basis is the current norm, with initiation treatment followed by maintenance therapy, Carl D. Regillo, MD, said. Alternatively, “treat and extend” is an option. We don’t know the dosing interval, he said. “The best outcomes appear to be when a great number of treatments are given with closer follow up.” The CATT study, which is looking at fixed vs. “traditional” as-needed dosing, expected to report in 2011, could affect the current, monthly dosing norm.

Nonresponders. One in 10 patients could lose three lines of vision despite ongoing anti-VEGF therapy, said Jason S. Slakter, MD. “It may be that we’re not managing these patients right.” Some nonresponders improve with resumption of treatment guidelines. “But some patients don’t respond.”

He identified several kinds of nonresponders, including those who need frequent re-treatment, and those who suddenly rebound after initial improvement. And there are “true” nonresponders, those who show minimal or no anatomic change despite treatment. In some cases, said Dr. Slakter, you have to consider that “maybe it’s not AMD.”

To better identify nonresponders Dr. Slakter urged less total reliance on OCT, and encouraged the use of ancillary testing with indocyanine green, fluorescein angiography and autofluorescence imaging.

Depending on the cause, nonresponders could benefit from combination treatment with intraocular steroids, laser or PDT. “Diagnosis is the key,” said Elias Reichel, MD, who also spoke of poor responders when making the case for judicious use of anti-VEGF agents. Some syndromes masquerade as AMD, and therefore may not respond to anti-VEGF treatment. Also, anti-VEGF can cause elevated IOP in a small percentage of patients, may reduce ocular perfusion, and could result in tachyphylaxis.

Avastin vs. Lucentis. Some 3,500 patients are expected to be enrolled in six trials in as many countries, pitting Avastin against Lucentis. CATT, the farthest along, should report next spring.  Stay tuned.—Miriam Karmel

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 Saturday, October 16

This year’s Subspecialty Day offerings included the latest research and clinical wisdom from experts in cornea, glaucoma, oculofacial plastic surgery, pediatric ophthalmology, refractive surgery, retina and uveitis. Here are some highlights.



No normotension glaucoma 

Alfred Sommer, MD, MHS, challenged glaucoma researchers and specialists Saturday to abandon the unfounded belief that 21 mmHg—or any single numerical value for intraocular pressure—will protect their glaucoma patients from optic nerve damage.

Dr. Sommer, professor of ophthalmology and epidemiology at Johns Hopkins University, and the former chair of its School of Public Health, presented the 2010 American Glaucoma Society Subspecialty Day Lecture.

Dr. Sommer leavened his criticism with plenty of humor. But the underlying message was dead serious: Ophthalmologists have allowed an arbitrary data point from Grant and Burke’s nearly 30-year-old landmark study to ossify into clinical dogma.

Originally, an IOP of 21 mmHg was merely an arbitrary data cutoff point (two standard deviations above the mean) for analyzing the relative risks of visual field loss in a very large cohort, he said. This statistical choice enabled Grant and Burke to propose elevated IOP as the central risk factor for progression of primary open angle glaucoma.1

But over time, 21 mmHg morphed from a statistical convenience into the boundary between “normal” and “elevated” IOP, Dr. Sommer said. “Somewhere along the line, 21 became defined as normal, when what it really reflected was what is common in the local population,” he said.

“And then we leaped to the unfounded conclusion that what is ‘normal’ must be okay.”

Confronted with the resulting paradox—that 50 percent of POAG patients who progress also have IOP lower than 21 mmHg—ophthalmology responded with a new patient category, normal-tension glaucoma, Dr. Sommer said.

It is time, he told the audience, to recognize the logical fallacies in this series of events. The relative risk of optic nerve damage is unquestionably related to IOP, but the risks are a continuum, not a dichotomy.

 “People intellectually know that what I am saying makes sense,” Dr. Sommer said later in an interview. “But the words we use to describe this disease distort our mental processes. If we keep clinging to the idea that POAG and normotensive glaucoma are somehow different diseases, we will be caught in a box. We are not going to be able to conceptualize what the other factors might be that influence who progresses and who doesn’t.”—Linda Roach

1 Grant W. M. and J. F. Burke. Ophthalmology, 1982;89:991–998.

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DALK: Why not now?

Even though it has been around for years and may offer some promising advantages over other procedures, deep anterior lamellar keratoplasty (DALK), an alternative to penetrating keratoplasty (PK) in eyes with keratoconus and stromal opacities, has yet to be embraced by the majority of corneal surgeons. During Cornea Subspecialty Day, George J. Florakis, MD, asked why this is the case and why he himself remains among the non-embracers.

He started off by presenting the theoretical and practical advantages of DALK. These include the fact that it does not require good donor endothelium and allows for longer donor time intervals (death to preservation and preservation to use); the potential for better visual outcomes than PK; a decreased chance of intraoperative choroidals and better wound strength compared to PK; and lower incidence of postoperative complications.

So what’s holding it back?

It’s technically difficult and takes longer than PK; good visual results may be unattainable if the “big bubble” technique doesn’t work; some studies have shown less myopic reduction compared to PK; and the astigmatism that results could be the same as or worse than PK, especially considering the difficulties in dealing with posterior stroma at the wound edge near Descemet’s.

Nevertheless, Dr. Florakis said, there is hope for DALK. It may, like its cousin deep lamellar endothelial keratoplasty (DLEK) just need time to mature. While many of its advantage are still only theoretical, they will probably prove to be real as surgeons build experience.

“It definitely has its benefits,” Dr. Florakis said. “I think it is now time to address and embrace DALK.”—Mark Simborg

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New test for distinguishing IV nerve palsy from skew deviation

Contest over!—When it comes to financial interests, pediatric neuro-ophthalmologists are among the least-conflicted doctors in the world. But they are the richest in pearls for saving kids’ vision and winning parents’ hearts.

Today’s neuro session from Pediatric Subspecialty Day, “Pearls and Pitfalls,” featured a number of wonderful pearls, including an especially compelling one from Agnes M. Wong, MD, PhD. Dr. Wong discussed a new test for distinguishing IV nerve palsy from skew deviation.

Dr. Wong noted that skew deviation can mimic a IV nerve palsy. Both are characterized by hypertopia in primary position, but IV nerve palsy is worse on ipsilateral head tilt and gaze to the opposite side, while skew deviation can be comitant, incomitant or alternating. The head tilt in nerve palsy is compensatory contralateral to the hypertophic eye, while the head tilt in skew deviation is part of the pathologic spectrum. Nerve palsy causes excyclotorsion 40 percent of the time, but no other neurologic signs, while skew deviation causes incyclotorsion in 80 percent of cases and usually is associated with other neurologic pathology, including ataxia and hemiplegia.

What is Dr. Wong’s new test to help the clinician catch a deviation mimicking a palsy? After dissociated vertical deviation, pseudostrabismus or mechanical restrictive causes have been ruled out, and the “3-step” test is positive, see if the vertical strabismus decreases, using a near target at 1/3 meter, when the child is repositioned from upright to supine position.

UtricleWhy this would work derives from the confluence of otology and ophthalmology: Utricles in the ear lie in a plane horizontal to gravity. If the vestibulo-ocular reflex projections from the utricles to ocular motorneurons are disrupted, skew deviation will result. This deviation will resolve or be reduced by more than 50 percent in supine position, potentially ruling out a IV nerve palsy with a sensitivity of 92 percent and a specificity of 100 percent. If it decreases by less than 50 percent in supine position, the diagnosis will either be found in the neuropathologic signs coincident with the skew deviation, or, alternatively, it is indeed a IV nerve palsy.—Denny Smith

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Collagen crosslinking may be approved in the United States by 2012

At today’s Refractive Surgery Subspecialty Day, J. Bradley Randleman, MD, today reported positive one-year results from the ongoing phase 3 study investigating corneal collagen crosslinking for progressive keratoconus and post-LASIK ectasia.

Sponsored by Avedro in the United States, there are 11 U.S. sites, with a total enrollment of 204 keratoconus eyes and 178 ectatic eyes. All sites are fully enrolled and currently completing six-month and 12-month follow-up visits, with the last patient visit scheduled for early 2011.

Dr. Randleman presented one-year results from one site headed by S. Peter Hersh, MD, that included 71 eyes, 49 with keratoconus and 22 with ectasia. At one year, mean Kmax decreased by 1.7 D and mean Kave decreased by 1.1 D. UCVA improved from 20/137 to 20/117, and BSCVA improved from 20/45 to 20/34.

Dr. Randleman said he expects trial results will be submitted for NDA approval in early 2011 and will be approved by the FDA in early 2012. “That’s about 10 years behind the rest of the world, if we can get it done this fast.”

He also described other active and anticipated U.S crosslinking trials investigating new treatment techniques that may maintain efficacy and improve safety and tolerability, including a multicenter, prospective, randomized trial evaluating epi-on and epi-off crosslinking; collagen crosslinking for keratoconus/ectasia with and without intacs; KXL, a method of accelerated crosslinking; and a multicenter, prospective, randomized trial using UV light.—Susanne Medeiros

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Innovation Summit hits a second home run

How does medicine efficiently and profitably get razor-edge ophthalmic technology out of inventors’ brains and into patients’ eyes? This was the topic under discussion at one of the most closely watched satellite meetings in Chicago, the 2nd Annual Ophthalmology Innovation Summit, which brought together more than 300 investors, researchers and industry captains and nearly 150 ophthalmic corporations and professional organizations.

Emmett Cunningham, MD, PhD, MPH, planned and chaired the event. Along with co-chairs William Link, PhD, and Gilbert Kliman, MD, Dr. Cunningham leveraged the success of last year’s 1st Ophthalmology Summit into an even more compelling event.

The heart of the summit was sessions showcasing the efforts of research in new ophthalmic medical devices and new biotechnologic agents. Taken as a whole, the projects filled an enormous range of intents, from orphan drugs for rare diseases to futuristic nanodevices for multibillion dollar markets.

Applied Genetic Technologies Corporation, sporting the acronym AGTC, is a good example of a young company tackling this broad range. Its portfolio includes virus-vectored proteins administered intravitreally to treat such pathologies as Leber congenital amaurosis and neovascular AMD. The return on investment for these projects, at a glance, could either dazzle or disappoint. Anti-AMD agents and glaucoma agents, for example, could capture a market share of $1 billion each for AGTC, while Leber research might only earn $6 million, at best. But the remark of one patient in the AGTC Leber study—“I saw fireworks for the first time”—matched an enthusiasm in the audience for improving lives as much as ROI.

Taligen Therapeutics is also addressing a range of treatments, all based on a deep understanding of the human complement system. Taligen considers that complement is the “fundamental biological pathway and a key regulator of innate immunity and inflammation, and a target-rich pathway for anti-inflammatory drug development.” The disorders Taligen is interested in treating with complement-based therapies include AMD and uveitis, as well as atypical hemolytic uremic syndrome, paroxysmal nocturnal hemoglobinuria, asthma, rheumatoid arthritis and lupus nephritis.

Other exciting avenues of research included:

  • A miniature compartmentalized cylinder, designed by On Demand Therapeutics, that is injected into the vitreous and safely keeps its drug contents dry until the ophthalmologist zaps the membrane of each compartment, one by one over a period of months, releasing the drug as needed into the posterior segment.
  • An iontophoretic drug delivery device is under development by EyeGate Pharmaceuticals. A drug-laden ocular applicator is placed on the eye and a generator is used to deliver a very low electric current. The electric field ionizes the drug particles, causing them to cross the cornea and migrate into the posterior segment.

Near the end of the Summit, smaller research endeavors heard from large ophthalmic companies some wise “dos and don'ts” of approaching another party for investment, merger or acquisition.—Denny Smith

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Sunday, October 17

Here is a further installment of highlights from the Academy in Chicago.



Ed Holland has the blues

Ed Holland He has been a magician, the king of Mardi Gras, a singer in a gospel choir, a salsa dancer and, today, one of the Blues Brothers. This year is Edward J. Holland’s last year as secretary for Annual Meeting. As the outgoing secretary, he once again outdid himself in his effort to bring a fine mix of entertainment and education.


Health care reform: End of the beginning, not the beginning of the end

Although the Opening Session of the Joint Meeting of the American Academy of Ophthalmology and the Middle East Africa Council of Ophthalmology began with a performance by the Blues Brothers—starring Edward J. Holland, MD, secretary for Annual Meeting as Elwood—Academy CEO David W. Parke, MD, struck a serious note about the changes health care reform will bring.

The challenges ahead are significant, he said, listing a number of changes that will likely occur in the future, such as being paid not for care provided but for the quality of care provided, as well as maintaining a license based not on paying a fee and taking CME courses, but by demonstrating continued clinical competence.

“It has been called the beginning of the end, but it’s far from it,” Dr. Parke said. “Not only has the fat lady not sung, she’s not even in the same time zone.” There is a lot of opportunity to shape the change that’s about to come.

Health care reform legislation passed earlier this year is replete with the phrase: “The secretary shall figure out the mechanism.” He said “secretary” refers not just to the secretary for Health & Human Services, but also to the secretaries for Labor and Treasury. The Academy is committed to working with Congress and other governmental agencies to “transform the ‘secretary shalls’” into a specific sets of rules and regulations that are clinically relevant and not excessively burdensome,” Dr. Parke said.

The key, he said, is to let policymakers and the public know the value of ophthalmology. Dr. Parke noted a variety of ways the Academy is working to educate the public, such as a video state societies can use to demonstrate the value of ophthalmology, the recently launched EyeWiki, an educational source for both physicians and the public, and the soon-to-be updated patient education website, EyeSmart.

The Academy is also working to quantify the value of care ophthalmologists provide with the help of the Hoskins Center for Quality Eye Care, a health policy research center with the goal of ensuring that patients continue to receive high quality, evidence-based eye care within a tightening economy that will demand increased value for any service provided.

Ultimately, Dr. Parke said, we need to view every patient as a potential advocate. “Patients will be the strongest advocate for the value of what we do.”—Susanne Medeiros

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Promising results for all-in-one femtosecond laser refractive surgery

On Saturday, during Refractive Surgery Subspecialty Day, Rupal Shah, MD, reported refractive outcomes using the ReLEx technique with a 500-kHz femtosecond laser (VisuMax) to treat myopia and myopic astigmatism. This laser is not yet available in the United States, but Dr. Shah said it holds “lots of promises.”

“ReLEx with a 500-kHz VisuMax laser has excellent stability, refractive outcomes and long term safety,” Dr. Shah said. “Results, except for the initial visual recovery, are, in my experience, comparable to, or even better than, the results for femto-LASIK.”

The procedure involves carving out a refractive lenticule within the corneal stroma with a femtosecond laser. The lenticule is then extracted from within the cornea, either by lifting a flap and peeling off the lenticule or by removing the lenticule through a 3-mm incision, also known as minimally invasive ReLEx or SMILE. Only a femtosecond laser is used for refractive correction. The procedure is completed in around 30 seconds.

Dr. Shah treated 150 eyes with myopia or myopic astigmatism between August 2009 and March 2010 as part of a prospective clinical trial. Spherical equivalent treated was –4.63 ± 2.64 D. Patients were followed for six months. At three months, all eyes attained BCVA that was the same or better than preop BCVA, and 97 percent of all eyes were within ± 0.5 D of the attempted correction. Of the full correction cases, 97 percent achieved UCVA of 20/20 or better. There was a 0.05-D change in the manifest refraction between one week and three months.

She concluded that this “procedure has the benefits of PRK without the pain and the benefits of LASIK without the flap.”—Susanne Medeiros

Dr. Shah is a consultant and lecturer for Carl Zeiss Meditec.

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Are new insertion devices for DSAEK surgery worth it?

During Saturday’s Cornea Subspecialty Day, Mark A. Terry, MD, presented an overview of new DSAEK insertion devices, comparing short-term data on the endothelial cell loss incurred with each. So far, none of the new devices has been proven to cause less damage than traditional forceps and glide techniques. Longer term data is required before we can assume inserters have better results.

Dr. Terry noted that recent studies show acute endothelial damage from insertion is related more to the size of the incision than to the insertion method. Data showed 3.2-mm incisions were associated with 40 to 44 percent cell loss, while 5.0-mm incisions are linked to 27 to 31 percent cell loss.

Dr. Terry reviewed the following insertion devices:

  • Neusidl Corneal Inserter (NCI): Tissue placed into a retracting platform for up to 8.50-mm grafts. No overlapping of tissue edges. Irrigation to maintain chamber built into NCI insertion tube. Minimum 5.2-mm incision size required.
  • EndoSaver: Similar to NCI but smaller insertion tube. Graft overlap occurs on retraction into smaller-diameter tube. Minimum 4.0-mm incision size required.
  • Tan EndoGlide: Similar concept to a closed-end Busin Glide. Tissue mounted with forceps into tube that rolls it into an “M” shape. Distal tube placed into minimum 3.5-mm incision and forceps pull-through technique used to position tissue into anterior chamber.

Dr. Terry concludes that the decision to use new insertion devices for DSAEK surgery should be based on the individual surgeon’s satisfaction with their current results using their current technique.

“The economic disadvantage of new insertion devices (about $100/case) should be weighed against the time commitment required for proficiency in established forceps and glide techniques. Both of which can yield comparable results as insertion devices.”—Susanne Medeiros

Dr. Terry receives lecture fees from Alcon, receives royalties from Bausch + Lomb and reports equity ownership/stock options in Optovue.

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Douglas A. Jabs surveys CMV/HIV co-infection in Jackson Memorial Lecture

Douglas A. Jabs, MD, MBA, a leading expert in inflammatory eye disease, delivered the Jackson Memorial Lecture at Sunday morning’s Opening Session. In his talk titled, “Cytomegalovirus Retinitis and AIDS: Bench to Bedside,” Dr. Jabs discussed the complex interaction between CMV retinitis and HIV, in which CMV affects the course of HIV infection, and how HIV treatment affected the course of CMV retinitis.

“The two in a culture will produce more virus than either one alone,” Dr. Jabs said. That knowledge led to the prediction that CMV infection would accelerate AIDS and death. 

The discovery of the synergy between CMV and HIV led to the highly active antiretroviral therapy (HAART) that has saved people from blindness and early death. Today, the combination of ganciclovir implants and systemic drugs has led to a 96 percent decrease in CMV retinitis, which pre-HAART led to bilateral blindness within 20 months. Earlier testing could lead to 100 percent success, Dr. Jabs said, but only about half of patients with HIV are aware of their status.

A further development that led to the effective management of CMV retinitis was the discovery that a blood sample could reveal what was going on in the eye. And treatment was further enhanced with the identification of all the gene mutations implicated in CMV retinitis drug resistance.

There is a downside: Immune recovery can lead to uveitis in as many as 18 percent of cases. Also, we continue to see retinal detachment at a rate 100-fold greater than in the regular population, even with recovery from CMV retinitis, Dr. Jabs said.

Also, patients are still dying and losing sight in countries where the rate of HIV is high and HAART is not available.

But the good news is that in the HAART era, the death rate has fallen from 30 percent to 1 to 3 percent.—Miriam Karmel

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The ups and downs of IOP fluctuation

Does fluctuation in IOP matter? It depends.

Speakers addressing IOP fluctuation at Saturday’s Glaucoma Subspecialty Day agreed that the answer is contingent upon your definition of fluctuation as well as the study you consult.

While the EMGT study found a strong effect of mean IOP on progression, it found no evidence that fluctuation was a risk factor. AGIS and CIGTS found that fluctuation had an effect when mean IOP is low, but not when it is high. Other data teased from AGIS found a higher probability of visual field progression with greater IOP fluctuation.

Despite the different results, Joseph Caprioli, MD, called the data complementary rather than contradictory. He took the “yes” side in a point-counterpoint discussion on whether clinicians should attempt to reduce IOP fluctuation, particularly in patients who appear to be getting worse at lower pressures.

Dr. Caprioli pointed out the need for continuous IOP monitoring to better understand fluctuation in pressure and how it relates to damage. He said researchers also need to understand why fluctuations might be damaging, suggesting that while regular peaks and valleys in IOP are normal, a disturbance in the “steady state” by irregular elevation of IOP could lead to damage.

The “no” argument was put forth by Arthur J. Sit, MD, who cited the lack of a standard definition of fluctuation as a drawback. Fluctuation has been reported as circadian, short-term (within a 24-hour period) or long-term (between office visits or even years). He added that most of the evidence for the effect of IOP fluctuation on progression comes from secondary analyses of large-scale trials. The studies show no evidence of causation, he said.

Though he argued the contrarian view, Dr. Sit confessed that he does reduce IOP fluctuation in his patients, by reducing IOP and increasing outflow. Many pharmacological treatments and surgical approaches achieve those goals, he said. So whether fluctuation is or is not an independent risk factor for glaucomatous damage, as Dr. Sit said: “Reduction of IOP fluctuation is a side effect of treatment.”—Miriam Karmel

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Women, blinding disease and eye care

Worldwide, 50 million people are blind; two-thirds of them are women. But gender bias is not limited to the developing world. For instance, of the 3.4 million visually impaired people in the United States, 2.3 million are women.

The gender disparity in eye health was the subject of an Academy news briefing Sunday morning. Explanations put forth to explain the phenomenon appeared to be mostly speculative, ranging from access to health care to perceived self-worth, to longer life expectancy, to low levels of education. But the speakers gave compelling evidence to support the assertion about gender inequity in eye care.

Manal Bouhaimed, MBChB, MSc, of Kuwait, reported that while AMD is more common among women, 70 percent of patients who were treated with photodynamic therapy at the only tertiary eye care center in her country were men. She added that blindness could be reduced by 11 percent in low- and middle-income countries if women received cataract surgery at the same rate as men, yet women are less likely to receive IOLs.

Lynn K. Gordon, MD, PhD, said that the Los Angeles Latino Eye Study (LALES) demonstrated that women are 20 percent more likely to have cataract than men, yet one-third of patients with cataract had an unmet need for surgery because of lack of health insurance.

Dr. Gordon noted that while greater life expectancy may account for some of the disparity, for example in conditions of aging such as AMD, access to care is a factor, especially for younger women. The female to male lifetime risk for AMD is 2:1. Also, women 75 and older are twice as likely to get eye exams as those who are 50 and under, which has implications for diabetes.

Women are 24 percent less likely to be treated for glaucoma, Dr. Gordon said. They also suffer disproportionally from eye trauma due to falls and from certain autoimmune diseases that cause vision problems.

Recognition of the problem is just beginning. “We need to generate evidence to support what we claim regarding gender inequality,” Dr. Bouhaimed said. “We must acknowledge that we have a problem and generate strategies for better and equal access.”

The chance for change is greater today than ever, said Ruth D. Williams, MD, in part because of the growing number of women Eye M.D.s. How else, she said, to explain the recognition of dry eye as a problem? “A whole bunch of women ophthalmologists have turned 50,” Dr. Williams said. “People have realized this is a disease state that has to be addressed.”—Miriam Karmel

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The $44,000 question: What is meaningful use of EHRs?

During Monday lunchtime, the HHS National Coordinator of Health IT—David Blumenthal, MD, MPP—will share insights on the government’s incentive program for electronic health records (EHRs). Physicians who start demonstrating meaningful use of a certified EHR system in 2011 or 2012 can receive up to $44,000 in incentive payments over five years.

Dr. Blumenthal’s talk will be the highlight of “Finally, a Meaning for Meaningful Use: Learn How to Qualify for EHR Incentive Payments,” a free Special Event on Monday, from 12:15 to 1:45 p.m. in Grand Ballroom S100AB.

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Stay Connected with the Community at the Joint Meeting

If you’re attending the Joint Meeting, or even if you can’t make it this year, you can stay informed about the latest buzz from Chicago. Visit the new “Live from Chicagopage for all the latest news from the online community and Twitter. You can contribute by sharing your daily pearls from Chicago at aao.org/chicagopearls and using the meeting hashtag #aaochi10 if you’re on Twitter.

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Monday, October 18

Here are some further highlights from the Academy in Chicago.



Kelman lecture: Aim high for your patients and your profession

This year’s Kelman lecturer, Douglas Koch, MD, presented a compelling overview of the tremendous challenges and opportunities that face ophthalmologists and their patients and offered his predictions for the next 10 years.

“Femtosecond lasers will become fully integrated into routine clinical practice,” he said. “We are just scratching the surface here. Femtosecond laser cataract surgery has the potential for creating perfect incisions, peripheral corneal limbal relaxing incisions, capsulorhexis and nuclear softening.”

There will be issues to sort out, such as extra time, cost and personnel required. “It’s a challenging and interesting technology that will change our field.” But will this evolution in technology lead to non-MDs performing the laser portion of cataract surgery? That’s an open question.

He believes presbyopia correction will become the norm in cataract and refractive procedures, with the choices in both lenticular and corneal approaches improving and proliferating to a dizzying degree, from accommodating IOLs, multifocal IOLs, LASIK/PRK with monovision, PresbyLASIK, intracorneal lens and small-aperture devices.

Dr. Koch offered up a scenario for the future in which ophthalmologists will provide several procedures for different situations and stages of life. A patient might get LASIK at 25, a PRK enhancement at 34, an intracorneal implant at 46, which would be removed at age 61 to take advantage of new technology, and a little wavefront adjustment at age 71. Expanding patient education and counteracting misinformation will play a key role in helping patients make the most of the new options.

But the current financial times and the pending physician shortage threaten to reduce the quality of care ophthalmologists can provide. Noting the Medicare cost for cataract-related procedures was $4.5 billion in 2009, or 0.83 percent of the total Medicare budget, “We are a sitting target for cuts,” he said, urging ophthalmologists to get involved in their state societies and be advocates for both their profession and their patients.

In order for patients to retain choices, he believes patients will likely have to pay for expanded care options, such as premium IOLs and new techniques.

He ended with a quote from Charles Kelman: “It becomes a matter of selecting the possible impossible dream. This is really the key to great success—evaluating your own aspirations—not setting them too low, but rather too high . . . just a little too high.”

For our patients and our profession, Dr. Koch said, “Let’s aim just a little too high.”—Susanne Medeiros

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Breakfast of champions for quality care

Randolph L. Johnson, MD Over breakfast this morning Cecil B. Wilson, MD, president of the AMA, Randolph L. Johnston, MD, president of the Academy and LaMar S. McGinnis Jr., MD, president of the American College of Surgeons, discussed the past, present and future of health care reform. Later, Drs. Wilson and McGinnis both presented the Parker Heath Lecture.

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Topography may be the most important tool for preventing post-LASIK ectasia

William B. Trattler, MD, made the case that topography is far more important than scoring systems for identifying which patients are at risk for post-LASIK ectasia. Dr. Trattler spoke during Sunday’s combined session with CLAO, “Ectatic Diseases of the Cornea: Treatment With Contact Lenses or Surgery.”

He believes the Risk Assessment Score for Ectasia After Corneal Refractive Surgery suffers from a major flaw in that it identified eyes as “normal,” topographically, even when the contralateral eye was not normal (patients presenting with forme fruste keratoconus, keratoconus or pellucid marginal degeneration, eyes with a residual stromal bed below 250 microns, and eyes that may have had deeper than expected flaps).

To test his assumption, he performed a retrospective review of 1,702 post-myopic LASIK eyes with normal topography and at least one year follow-up. Using the risk assessment score would have excluded 12.22 percent of these patients from LASIK. But none of them had developed ectasia at one year.

Dr. Trattler also took issue with the commonly held belief that thin corneas are a risk factor for ectasia. “Pundits suggest that a cornea that is beyond 2 standard deviations of average is ‘abnormal,’” he said. But if topography is normal in both eyes, a thinner cornea does not increase the risk for ectasia.

“There are no studies to support an increased rate of ectasia in thin corneas with normal topographies,” he said. “Six peer-reviewed articles on LASIK in thin corneas with normal topography show no cases of ectasia.”

Dr. Trattler performed an additional retrospective review of 166 eyes with post-LASIK ectasia to further evaluate risk factors. Only three eyes with bilateral normal topographies and preoperative corneal thickness less than 500 microns developed ectasia. He notes that surgery for these eyes occurred in 1999 and 2000, before IntraLase, and no flap thickness measurements were performed. “Maybe they went too deep with the microkeratome,” he said.

Dr. Trattler concludes that the “most important parameters are careful evaluation of corneal shape in both eyes with topography, and be careful not to go too deep. Getting intraoperative pachymetry is important.”—Susanne Medeiros

Dr. Trattler has financial disclosures relating to Alcon, Allergan, AMO, CXLUSA, Fera Pharmaceuticals, Inspire, Ista, LensAR , Lenstec, QLTI and Santen.

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Applying results from the DRCR.net re-treatment algorithm for DME

Earlier this year the Diabetic Retinopathy Clinical Research Network (DRCR.net) published a study involving its 52 clinical sites. The results showed that nearly 50 percent of patients who received ranibizumab plus laser treatment experienced substantial visual improvement after one year, compared with 28 percent who received standard laser treatment.

During Retina Subspecialty Day on Saturday, Susan Bressler, MD, offered guidance on how to apply the re-treatment algorithm from this important study to clinical practice.

“Understanding how they managed the patient is critical to applying the study results to clinical practice,” Dr. Bressler said. “Patients were seen every single month for the entire first year and were re-treated based on a 4:2:7 guide. It’s pretty complicated.”

You can view Dr. Bressler’s presentation in its entirety. —Susanne Medeiros

Dr. Bressler receives grant support from Genentech.

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Oculoplastic surgery rejuvenates the entire face

The expectations of patients seeking cosmetic facial improvement are understandably high, but their hesitation to agree to a substantial, comprehensive surgical solution can hamper the ability of the oculoplastic expert to meet those expectations.

In “The Aesthetic Evaluation,” moderated by Jill A. Foster, MD, at Friday’s Oculofacial Plastic Surgery Subspecialty Day, oculoplastic surgeons were encouraged to evaluate a patient’s entire face and consider an approach to rejuvenation that is based on a hands-on assessment of the face and that does not hesitate to rely on the entire oculofacial surgical armamentarium. One of the presenters, Patrick M. Flaharty, MD, calls this approach “panfacial rejuvenation.”

Brett S. Kotlus, MD, explained that faces age with three characteristic patterns: photoaging damage from sunlight, deflation resulting from loss of bone, collagen and subcutaneous fat, and gravitational descent resulting in sagging of the facial tissues.

The patient assessment as performed by John H. Hunts, MD, includes evaluation of skin tone and laxity, fat location and depletion, jowling, bone profiling and the scoring of damage from sun exposure, intrinsic aging or cigarette use. This assessment requires that the surgeon not hesitate to touch the face and manipulate the patient’s tissue, he said.

Nonsurgical solutions, such as chemodenervation and laser resurfacing, can provide temporary, subtle improvements in the patient’s look, especially in younger patients who still have nice skin tone. But a substantial or dramatic difference, especially in older patients, is only really available through surgery, Dr. Kotlus said. The surgeon planning a panfacial surgical solution will essentially act as a sculptor, adding volume in some areas with implants, fillers or fat relocation, and subtracting in others, with resection or liposuction.

In middle-aged men and women with some brow ptosis and deepened tear troughs, Tanuj Nakra, MD, has achieved nice results with fat transfer to the lateral brow and filling of tear troughs. For substantial results designed to address a patient’s full concerns, he might include a blepharoplasty, canthoplasty, fat transfer, endoscopic brow lift and orbicularis suspension, all in the same surgical setting, and then enhance or maintain those results with nonsurgical adjuncts like chemical peels and nutraceuticals like vitamin C and retinol to stimulate collagen production and reduce pigment and inflammation.

Unfortunately, patients who want dramatic improvements but who are hesitant to undergo comprehensive surgical solutions are often the very ones who are disappointed in the results of piecemeal efforts. Dr. Flaharty readily understands that patients dread looking like they just had plastic surgery and therefore often limit the intervention to less than what the oculoplastic surgeon recommends. But he said that a comprehensive surgical approach is exactly what will accomplish a natural, harmonious result in most patients.—Denny Smith

Dr. Foster is a consultant to and lecturer for Allergan. Drs. Flaharty, Kotlus, Hunts and Nakra report no interests.

Brow Lift
Direct brow lift in a middle-aged man.

Tear Filler
Cheek and tear tough were filled simultaneously in this young woman.

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Ethics in neuro-ophthalmology: apologize and refer

All practicing ophthalmologists are familiar with the traditional paradigms of analyzing what went wrong: tests, case histories, etcetera, etcetera. But what happens when a potential violation of ethics is involved? What is the proper way to measure what went wrong?

In this morning’s course, “The Consequences of Poor Decision-Making in Neuro-Ophthalmology,” Bradley K. Farris, MD, and Thomas J. Whittaker, JD, MD, set out to extrapolate “ethical algorithms” for analyzing what went wrong using eight very tough, real-life cases with real-life consequences, a few of which they were directly involved in. “There’s always going to be a blur between your ethical duty and your legal duty,” Dr. Farris said. “Your legal duty is what you have to do, and your ethical duty is what you ought to do.”

They started off by presenting “the unforgiving algorithm,” which includes missed diagnoses, the overlooking of signs or symptoms, missed or inappropriate work-ups, delayed or inappropriate treatments, refusing to refer, and not listening.

Turns out this algorithm was present in nearly every case they presented.

One case involved a woman who awoke from elective endoscopic sinus surgery blind in one eye. Subsequent investigation revealed that during the operation the OR nurse had repeatedly advised the ophthalmic surgeon that the woman’s eyes “jerked” with each biopsy. The surgeon refused to listen to her, and finally threw her out of the operating room for continuing to point this out. The lesson? “There’s a certain duty you have in respecting your colleagues, and that duty is listening,” Dr. Farris said. “This particular surgeon was not aware of the potential complications of the procedure and did not share them with his patient.”

In another case, a 72-year-old woman with a two-year history of progressive diplopia went in for a CT-scan that was interpreted as normal. Later examination with a neuro-ophthalmologist using CT scan with infusion, however, revealed cranial nerve palsies. In slides presented to the audience, Dr. Farris pointed out the abnormality in the original, noninfusion CT scans, which later proved to be a tumor. The abnormality, while faint, was visible even to the untrained eye.

“This was not malpractice but a breach of duties,” Dr. Farris said. “Even in the best of worlds, she [the patient] was probably going to have this problem anyway. But the first radiologist had an ethical obligation to refer.”

Another case of what turned out to be an orbital fracture created by a mistake during surgery turned into a finger-pointing match between the neurologist and the ENT. “All this woman was looking for was help,” Dr. Farris said. “But none of the surgeons would be humble and admit responsibility.” 

This lack of humility, said Drs. Farris and Whittaker, is one of the primary causes of most malpractice suits; most patients are simply looking for an apology and an explanation of what happened. “Taking that humble stance is hard,” Dr. Farris said. “For whatever reason, it’s hard for us.”

The overriding ethical algorithm, then? Humility. “If you’re stuck and you’re not sure and the patient is really suffering,” Dr. Farris said, “find someone who can help. When in doubt: refer, refer, refer.”—Mark Simborg

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Coming soon: generic latanoprost

Latanoprost, the most widely prescribed IOP-lowering medication, goes generic in the spring of 2011. What impact the change will have on glaucoma practice is anybody’s guess, but it’s likely to be significant. That, at least, was the consensus among a panel of glaucoma experts who engaged in an hour-long, free-wheeling discussion on various aspects of everyday clinical practice at the Academy Café on Monday morning.

“It’s going to be a huge deal,” said Cynthia Mattox, MD, when asked how the introduction of generic latanoprost will affect the practice landscape. Speaking from past experience when other drugs went generic, Dr. Mattox predicted that physicians’ prescribing options will be curtailed by insurers who want to preclude them from using the more expensive brand label. “You’re fighting the uphill battle if there’s a generic,” she said.

Thomas W. Samuelson, MD, who chaired the panel, said such restrictions are problematic when the generic drug isn’t well tolerated by patients. “It’s always a good thing to make medications more affordable,” he said, “but the quality of the vehicle is also important.”

Douglas J. Rhee, MD, agreed that tolerance is important. “It’s the rare patient where the generic isn’t as efficacious,” he said. But about 75 percent of patients complain that stinging is worse when they switch to the off-brand drug. To further complicate matters, Dr. Rhee noted that more than one generic product is likely to enter the U.S. market.

The upside is that a plethora of drugs opens the way for a comparative study. Kuldev Singh, MD, MPH, predicted that the introduction of generic latanoprost will provide the first time in ophthalmology when a study on generics is likely. Such a study should be well received. “You can’t write a prescription for a specific generic,” Dr. Singh said, but if doctors know which generic is most effective they may seek out pharmacies that dispense a particular brand. “This has never happened before,” he said. “It’s going to be a big issue.”

In a related matter, it was noted that in June 2010, CMS clarified its Part D rules to permit refills on topical ophthalmic products at 70 percent of the predicted days of use. That means 30-day prescriptions may be refilled at 21 days.

This year’s Academy Café program will conclude with a Cataract session on Tuesday from 9 to 10:15 a.m. in Room S406B.—Miriam Karmel

Dr. Rhee receives grant support from Pfizer. Dr. Samuelson is a consultant to Pfizer. Drs. Mattox and Singh report no interest in Pfizer.

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Preliminary registration numbers announced

In a preliminary tally, the number of people who had registered as of Sunday for the Chicago meeting was 26,425. The number of physicians who had registered was 14,819; 9,272 are from the United States and 5,547 are visiting from other countries.

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Best Papers

During several of the Free Papers sessions, the expert panels moderating those presentations named the paper they rated most highly.

The Best Papers on Sunday were:

Cataract Original Papers—Femtosecond Laser session
Choice of Fragmentation Algorithm Impacts the Reduction in Cumulated Dissipated Energy During Cataract Surgery, presented by Harvey S. Uy, MD, in the absence of the original presenting author Louis D. “Skip” Nichamin, MD (event code PA003).

Oculoplastics Original Papers—Ocular Tumors/Pathology
Determination of the Radioactive Dose to the Surgeon During Plaque Brachytherapy, presented by Jose S. Pulido, MD, MS (event code PA010).

Oculoplastics Original Papers—Orbit, Lacrimal, Plastic Surgery  
Retroocular Hemodynamic Changes After Orbital Decompression in Graves Ophthalmopathy as Evaluated With Color Doppler Imaging, presented by Marta Pérez-López, MD (event code PA012).

Retina/Vitreous Original Papers, Part 1
Meta-analysis of Endophthalmitis After Intravitreal Injection of Anti-VEGF Agents: Causative Organisms and Prevention Strategies presented by Colin A. McCannel, MD (event code PA020).
  
Retina/Vitreous Original Papers, Part 2
DA VINCI—DME and VEGF Trap-Eye: INvestigation of Clinical Impact: Phase 2 Study in Diabetic Macular Edema, presented by Diana V. Do, MD (event code PA028).

The Best Papers on Monday were:

Neuro-Ophthalmology Original Papers
Cerebrospinal Fluid and Blood Flow Dynamics in Idiopathic Intracranial Hypertension, presented by Byron L. Lam, MD (event code PA072).

Pediatric Ophthalmology Original Papers
Infant Aphakia Treatment Study: Effects of Persistent Fetal Vasculature on Outcome, presented by David G. Morrison, MD (event code PA056).

Cornea/External Disease Original Papers, Part 1
A Stepwise Approach to Donor Preparation and Insertion Increases Safety and Outcome of Descemet Membrane Endothelial Keratoplasty, presented by Friedrich E. Kruse, MD (event code PA054).

Cornea/External Disease Original Papers, Part Two
Two-Year Corneal Crosslinking Results in Pediatric Patients With Documented Progressive Keratoconus, presented by Elena Albe, MD (event code PA065).

Glaucoma Original Papers
The Effect of Cataract Surgery on Trabeculectomy Function, presented by Rahat Husain, MBBS (event code PA043).

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Exhibition—President Obama’s Health IT chief visits the Academy’s Electronic Office

Dr. Blumenthal“Today, I had a chance to look at the use of electronic health records in the office of the future,” said David Blumenthal, MD, MPP, the HHS National Coordinator of Health IT, after visiting The Electronic Office (Booth 3967). This exhibit demonstrates how electronic health records (EHRs) can be integrated with devices. “I was truly impressed by the work that is going on in your discipline to take the very complicated data and imagery that you collect and organize it into an interoperable record.” Dr. Blumenthal was in Chicago to receive the Academy’s Visionary Award and to share insights about the government’s EHR incentive program during Monday lunchtime’s free symposium, “Finally, a Meaning for Meaningful Use: Learn How to Qualify for EHR Incentive Payments.” In early November, this presentation will be downloadable at www.aao.org/ehr.

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Order the Subspecialty Day 2010 and Joint Meeting DVDs

Extend your meeting experience with the Subspecialty Day 2010 and Joint Meeting DVD-ROM Archives. Containing high-resolution video of presenter slides with synchronized audio, the DVDs replicated the experience of attending the program. It also offers maximum flexibility to watch anytime, anywhere with DVD-ROM archive and online access. See for yourself. View Susan Bressler’s presentation describing how to apply results from the DRCR.net retreatment algorithm for diabetic macular edema to clinical practice.

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Academy content now available on Eye Handbook for the iPhone

Just released at the Joint Meeting: The latest version of the free Eye Handbook application for the iPhone now features select Academy Summary Benchmarks for Preferred Practice Pattern Guidelines and patient education videos. This is a collaboration between the Academy and the three ophthalmologists (Cloud Nine Development) who created the Eye Handbook, which offers ophthalmic calculators, clinical videos, coding resources and much more. Get the free Eye Handbook on iTunes, and learn more by visiting Cloud Nine Development in the Joint Meeting exhibit hall, Booth 3575.

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