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November 2012

 
 
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Academy Live 2012

Academy Live is a series of four daily e-newsletters with onsite reporting to bring you the clinical highlights from this year's Subspecialty Day and Joint Meeting. Look for it in your inbox or read it below.


Friday, November 9  

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Chicago welcomed thousands of subspecialists today as the Academy’s Refractive Surgery and Retina Subspecialty Day meetings commenced. Here are some highlights from today’s sessions.


Assessing therapeutic targets for early AMD
In the 2012 Schepens Lecture, during Retina Subspecialty Day, Alan C. Bird, MD, provided an overview of how our understanding of the nonneovascular AMD disease process has shifted over time

The presence and size of drusen have long served as the marker for dry AMD. However, early changes in AMD have also been shown to affect the choroid, Bruch’s membrane, retinal pigment epithelium and photoreceptor cells, which should be evaluated in addition to drusen. It’s increasingly apparent that a one-size-fits-all approach to therapy for dry AMD is an outmoded idea, said Dr. Bird.

Moreover, these early changes vary “enormously” from patient to patient, said Dr. Bird. This hands researchers a new challenge: the need to “phenotype more carefully” as they select cases for clinical trials and monitor therapeutic response to interventions. It also opens the door to developing new therapies based on phenotyping, he said.—Jean Shaw

Dr. Bird reports no related financial interests.

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LASIK in thin corneas: Where do we draw the line?
Refractive Surgery Subspecialty Day kicked off with a passionate debate about whether LASIK is safe to perform in thin corneas, and if so, how thin?

“There is no magic number below which ectasia occurs and above which LASIK is safe,” said R. Doyle Stulting, MD, PhD, who took the podium first to argue that LASIK should not be performed in thin corneas. However, said Dr. Stulting, according to the literature, the risk of ectasia is 3.2 percent in corneas that are less than 480 µm thick. Dr. Stulting cited numerous studies, including one meta-analysis, showing that the thickness of the cornea and residual stromal bed predict ectasia after LASIK.

But a thinner cornea is not necessarily a weaker cornea, nor is a thicker cornea necessarily a stronger cornea, argued William Trattler, MD, in his counterpoint.

He cited one retrospective study he conducted in which most cases of post-LASIK ectasia occurred in patients with corneas thicker than 500 µm. What we should be paying most attention to is topography, said Dr. Trattler. “If the topography is abnormal in either eye, corneal thickness is irrelevant,” he said. “If the topography is bilaterally normal, then central corneal thickness does not influence the risk of ectasia.”

But it was the panel, consisting of Deepinder K. Dhaliwal, MD, A. John Kanellopoulos, MD, and Michael C. Knorz, MD, that would have the final say. “In a way, both speakers are right,” said Dr. Knorz. The consensus was that predicting post-LASIK corneal ectasia is still very much an inexact science. What’s needed, they agreed, is a reliable biomechanical index that incorporates all of the variables for predicting how corneas behave.—Mark Simborg.

Dr. Stulting is a consultant to Abbott Medical Optics, Alcon Laboratories, Calhoun Vision, NuLens, Topcon Medical Systems and Vision Care Ophthalmic Technologies, and receives lecture fees from Alcon and Allergan. Dr. Trattler is a consultant to Abbott Medical Optics, Allergan, Aton Pharmaceuticals, CXLUSA, EyeGate, Inspire Pharmaceuticals, LensAR, QLT Phototherapeutics and Tear Science; receives lecture fees from Abbott Medical Optics, Allergan and Inspire Pharmaceuticals; and receives grant support from Abbott Medical Optics, Allergan, Bausch + Lomb, Inspire Pharmaceuticals, Ista Pharmaceuticals, QLT Phototherapeutics and Rapid Pathogen Screenings.

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Genetic testing for AMD: yes or no?
In a packed Retina Subspecialty Day session, presenters debated whether clinicians should offer genetic testing for AMD to their patients.

Pros. Mark S. Blumenkranz, MD, outlined the following arguments in favor:

  • As genetics is thought to account for only 60 to 70 percent of the identifiable risk factors, testing could spur patients to take control of modifiable risk factors such as smoking or diet.
  • Testing could identify those patients at increased risk of developing the disease; if done early enough in a patient’s lifetime, the results could encourage the person toward “active management of environmental factors,” Dr. Blumenkranz said.
  • Testing could guide drug therapy for patients who have developed the later stages of the disease.
  • Testing could prove valuable in alleviating anxiety in younger patients who have a family history of the disease.

Cons. Frederick L. Ferris, MD, acknowledged that genetic testing has an important role in research, but its value is not yet supported in the clinical setting. He offered a caution—“If you do genetic testing, you’re obligated to do genetic counseling”—and noted the following:

  • A simple, inexpensive clinical method already exists for providing patients with an estimate of their risk of progression to vision loss. This involves counting the presence of large drusen and/or pigmentary changes during a dilated eye exam in each eye.
  • This basic risk estimate can be further refined by assessing the patient’s environmental risk factors.
  • Adding genetic information will not significantly change how a patient is treated or followed and, thus, is essentially “clinically meaningless” with regard to patient management, Dr. Ferris said.

Audience vote. Audience members agreed with Dr. Ferris, voting 92 to 8 percent against offering routine genetic testing for AMD as part of their clinical practice.—Jean Shaw

Dr. Blumenkranz is a consultant to Ista Pharmaceuticals and Vantage Surgical; is an equity owner of Avalanche Biotechnology, Digisight, Optimedica and Vantage Surgical; and has a patent/royalties interest in Avalanche Biotechnology and Optimedica. Dr. Ferris has a patent/royalties interest in Bausch + Lomb.

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Effect of collagen cross-linking on limbal stem cells
Stem cells of the corneal limbus appear not to be damaged by corneal cross-linking (CXL) even when the ultraviolet A (UV-A) dosing is in the corneal periphery, reported Swiss researchers during today’s Refractive Surgery free papers session.

The stem cells functioned normally, re-epithelializing the surface even after the corneal periphery was irradiated with UV-A energy of 10 mW/cm2 for 30 minutes, said Olivier Richoz, MD. (Standard CXL protocols use 3 mW/cm2 for 30 minutes.)

Although the study was conducted in rabbits, its findings provide some reassurance for ophthalmologists who are stabilizing patients’ corneas with CXL treatment, said Dr. Richoz.

“We can cross-link the cornea very near the limbus without stem cell toxicity. We saw no evidence of thrombosis on a macro- or microscopic level. For conditions such as pellucid marginal degeneration, peripheral treatment is required, so this is important to know,” he said.

There were no delays in re-epithelialization, which reflects limbal stem cell health, even with large UV-A doses. “This means the stem cells are more resistant to the free radicals generated during cross-linking than epithelial cells are.”

Limbal stem cells also are known to resist the harmful effects of cancer chemotherapy, said Dr. Richoz, who coauthored the paper with Farhad Hafezi, MD, PhD.—Linda Roach

Dr. Richoz reports no related financial interests.

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What’s new with dyes?

Staining the posterior hyaloid, epiretinal membrane and internal limiting membrane tissues gives vitreoretinal surgeons the upper hand during vitrectomy, said Lihteh Wu, MD, during Retina Subspecialty Day.

He provided an overview of where we are with chromovitrectomy.

Current options. Indocyanine green, trypan blue, brilliant blue G and triamcinolone acetonide remain the current mainstays.

In the pipeline. Dyes being studied include those derived from the acai berry, cochineal, lutein and zeaxanthin, and chlorophyll.

The big question. Toxicity remains the primary concern with all dyes, said Dr. Wu. To minimize toxicity, he recommended three primary tactics:

  • Lower the concentration.
  • Use the dye for a shorter period of time.
  • Keep the light pipe away from the macula.—Jean Shaw

Dr. Wu receives lecture fees from Heidelberg Engineering.

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The quotable ophthalmologist
“Unfortunately, some people end up in the wrong place at the wrong time. Unfortunately, that can happen to the retina,” said Carl C. Claes, MD, who was voted winner of the “My Coolest Surgical Video” during today’s Retina meeting.

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Saturday, November 10  

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Dr. Zaiba Malik talks to the innovator of the glued IOL, Dr. Amar Agarwal, who describes the critical handshake technique

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A refreshing approach to professional education at the plastics subspecialty day

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Highlights from the Friday and Saturday Subspecialty Day meetings.

Corneal CXL and LASIK?
Don’t combine routine corneal cross-linking (CXL) with primary LASIK. This was the contention of Perry S. Binder, MD, during a session at the Refractive Surgery meeting on Friday. “Do not perform corneal cross-linking on primary LASIK cases until we can determine the risk and benefits. If in doubt about a possible high-risk case, consider PRK or a phakic IOL.”

He noted that some arguments can be made for routinely performing CXL at the time of LASIK, particularly the fear of post-LASIK ectasia and the inability to detect all at-risk patients.

However, Dr. Binder said that these considerations are outweighed by the potential risks of combining these procedures. Among the potential risks are:

  • Infection due to increased surgical manipulation and bed exposure time
  • Possible deep stromal cell loss compared with more superficial loss seen with LASIK alone
  • Variations in ultraviolet A (UV-A) and riboflavin diffusion
  • Unknown effects on stability of refraction as well as on primary and enhancement excimer laser ablation rates
  • UV-A exposure of other ocular tissues, such as corneal stem cells, conjunctiva and lens

He added that the incidence of post-LASIK ectasia is decreasing, and methods for detecting risk are improving, such as better topography algorithms and measurement of epithelial thickness to detect abnormal eyes early.
—Lori Roniger

Dr. Binder is a consultant to Abbott Medical Optics, AcuFocus and Stroma; receives lecture fees from Abbott Medical Optics and AcuFocus; has an equity interest in AcuFocus; and has a patents/royalties interest in Outcomes Analysis Software.

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Reconsidering chronic conjunctivitis
Mucous membrane pemphigoid, or ocular cicatricial pemphigoid (OCP), is a systemic autoimmune disorder that produces progressive conjunctival cicatrization with secondary blinding keratopathy, said C. Stephen Foster, MD, on Saturday at the Uveitis meeting. “What we see clinically is conjunctivitis.”

Lesion production is a “two-hit hypothesis,” involving genetic susceptibility and environmental triggers (including systemic medications, topical medications and microbes), said Dr. Foster.

  • Signs. These include chronic conjunctivitis and subepithelial fibrosis, fornix foreshortening, symblepharon formation and end-stage keratinization. If the first three are observed, the patient can “still be saved,” Dr. Foster said. However, once end-stage keratinization occurs, it’s “game over.”
  • Treatment. OCP must be treated systemically; current treatment is immunodulatory therapy, Dr. Foster said.
  • Complications. OCP can be fatal if it involves the esophageal or nasopharyngeal tissues.
  • Heads up. Dr. Foster outlined a number of factors involved in the disease progression and offered this warning: “For those of you who are not taking notes, this information will be on the American Board of Ophthalmology examination.”
    —Jean Shaw

Dr. Foster is a consultant to and receives grant support from Abbott Medical Optics, Alcon Laboratories, Allergan, Lux Biosciences and Novartis Pharmaceuticals. He also receives grant support and has an equity interest in Eyegate Pharmaceuticals.

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What’s new with dyes?
Staining the posterior hyaloid, epiretinal membrane and internal limiting membrane tissues gives vitreoretinal surgeons the upper hand during vitrectomy, said Lihteh Wu, MD, speaking at the Retina meeting on Friday. He provided an overview of where we are with chromovitrectomy.

Current options. Indocyanine green, trypan blue, brilliant blue G and triamcinolone acetonide remain the current mainstays.

In the pipeline. Dyes being studied include those derived from the acai berry, cochineal, lutein and zeaxanthin, and chlorophyll.

The big question. Toxicity remains the primary concern with all dyes, said Dr. Wu. To minimize toxicity, he recommended three primary tactics:

  • Lower the concentration.
  • Use the dye for a shorter period of time.
  • Keep the light pipe away from the macula.—Jean Shaw

Dr. Wu receives lecture fees from Heidelberg Engineering.

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For nonspecialists: how to manage immunomodulatory therapy
Your uveitis patient needs immunomodulatory therapy, but you are neither an ocular immunologist nor a uveitis specialist, and there is no uveitis specialist in your area. What next? During Saturday’s Uveitis meeting, Justine R. Smith, MD, suggested taking the following steps.

Do the workup. It’s essential that you rule out infectious etiologies or a masquerade syndrome and identify any systemic associations. “This is the ophthalmologist’s job; a chemotherapist can’t be expected to exclude these,” Dr. Smith said. As part of the workup, be sure to order all appropriate baseline tests, including a complete blood count with differential, biochemical analyses, tuberculosis screening, and hepatitis B and C serology.

Identify the appropriate colleague. Don’t automatically assume that this person will be a rheumatologist; a gastroenterologist, neurologist or nephrologist might be the better choice. “Different internal medicine specialists have more or less experience with different drugs.”

Consider other specialists as needed. These might include a pediatrician, an infectious disease specialist (if the patient has tuberculosis or HIV) or a perinatologist (if the patient is pregnant).

Participate in treatment decisions. With regard to drug selection, you have access to clinical literature that internal medicine specialists might not be aware of (and vice versa).

Communicate, communicate, communicate. Keep your colleague informed about the patient’s ocular status. For instance, after each eye exam, follow up by letter, she said. However, “Be careful to avoid ophthalmology jargon; that drives our rheumatology colleagues crazy.” She also cautioned against cutting and pasting from your EHR files. In addition, be sure to continue to communicate with the patient, asking about such issues as compliance and symptoms.—Jean Shaw

Dr. Smith has received grant support from Collins Medical Trust and the National Eye Institute.

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Infectious uveitis: a world of hurt
Depending on where you live in the world, infectious uveitis accounts for 10 to 60 percent of all uveitis cases, said Rubens Belfort Jr., MD, PhD.

“Infections are more important than ever,” he said. “There are new pathogens, and new entities related to old pathogens.” Moreover, new diagnostic techniques are reshaping our awareness of the scope of the problem, with some pathogens previously considered noninfectious now undergoing reclassification, he explained.

Etiology. More than 100 bacteria, viruses, parasites and fungi are implicated; potential suspects include toxoplasmosis, West Nile virus, cytomegalovirus, Borrelia and Bartonella. Ocular toxoplasmosis is the most important and frequent cause of infectious retinal disease and posterior uveitis.

Diagnosis. A revolution in diagnosis is expected, with novel tests providing more precise and faster results. In particular, Dr. Belfort cited the panmicrobial oligonucleotide assay and the universal diagnostic bacterial, viral and fungal kits.

The bottom line? “Think infection; think unusual infections,” Dr. Belfort said. “Think medically, with regard to the whole picture.”—Jean Shaw

Dr. Belfort is a consultant to Alcon Laboratories, Allergan and Bayer; receives lecture fees from Alcon and Allergan; and receives grant support from Alcon Laboratories and Allergan.

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Speakers make the case for and against monovision laser correction
“I would argue that modified monovision is the way for laser vision correction,” said Dan Z. Reinstein, MD, during a point-counterpoint session on Friday at the Refractive Surgery meeting. However, David Hardten, MD, argued, “For routine cases, pushing for monovision creates a whole new set of challenges,” and patient selection is difficult.

“There’s always a compromise to be made” between maintaining optical quality and binocularity, said Dr. Reinstein. He added that safety and quality of vision remain compromised with multifocal laser vision correction, since the brain has problems adapting to multiple intraocular images. He described monovision as more natural, but not everyone tolerates it. With traditional monovision, some patients can have poor intermediate vision and reduced contrast sensitivity and stereoacuity.

However, the disadvantages of monovision can be reduced with modern monovision, also called micro-monovision or laser blended vision, which produces better vision with less compromise than with multifocal vision, he said. With this technique, the nondominant eye is set to be slightly myopic (less than 1.50 D), while the dominant eye is fully corrected for distance. This way, the depth of field of the dominant eye is from distance to intermediate vision, while for the nondominant eye, it is from near to intermediate range. When anisometropia is limited to less than 1.50 D, spectacles can be easily tolerated, whereas with larger degrees of anisometropia, it is more difficult to tolerate.

On the other hand, Dr. Hardten pointed out, stereopsis is decreased with monovision, which can also precipitate strabismus. Additionally, binocular vision and contrast sensitivity can be worse with monovision, and this may decrease walking speed and patient confidence while ambulatory. Enhancements, which can be common with monovision, do carry some risk, he said.—Lori Roniger

Dr. Hardten is a consultant to Abbott Medical Optics, Allergan, Bausch + Lomb, Bio-Tissue, ESI and TLC Vision; receives lecture fees from Abbott Medical Optics, Allergan and Oculus; and receives grant support from Abbott Medical Optics, Allergan, Calhoun Vision and Topcon Medical Systems. Dr. Reinstein is a consultant to Carl Zeiss Meditec and is an equity owner and has a patent/royalties interest in Arcscan.

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Novel endoscope for vitreoretinal surgery
“Everything you learn in this meeting will be useless unless you have a view to the back of the eye,” said Jorge G. Arroyo, MD, on Friday at the Retina meeting.

The solution? A combined diode laser and endoscopy unit from Endo Optiks. In a series of video clips, Dr. Arroyo outlined the endoscope’s value in a number of procedures, including vitrectromy, membrane peeling and endoscopic cyclophotocoagulation.

Pros. Visualization and field of view are significantly enhanced, he said. The system allows for excellent panretinal photocoagulation treatment in patients with peripheral ischemic retinopathies and has proved particularly effective in patients with neovascular glaucoma.

Cons. Negatives include a learning curve, the lack of stereopsis and a suboptimal view with a 23-gauge probe.—Jean Shaw

Dr. Arroyo reports no related financial interests.

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The quotable ophthalmologist
Before launching into his presentation “Pitfalls in Interpreting Spectral Domain OCT” at Glaucoma Subspecialty Day, Sanjay G. Asrani, MD, showed this slide of a sign in his office: “Caution: This machine has no brain. Use your own.”

“It’s better for the patient to be uncomfortable for three minutes than for you to be disabled from a herniated disc for a lifetime,” said Deepinder K. Dhaliwal, MD, during today’s Cornea meeting. (And if you wish to avoid a herniated disc, attend the free lunchtime event “Ergonomics/Musculoskeletal Disorders in Ophthalmologists” on Monday, 12:45-1:45 p.m., in Room N427d.)

While discussing how to manage tough AMD cases, Lawrence J. Singerman, MD, noted, “I would definitely consider thermal laser—some of you may not have heard of that.”

Before a panel discussion about managing AMD, Lawrence A. Yannuzzi, MD, said: “Wow, what exciting graphs! Charts! Conclusions! Please don’t expect that from us.”

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Sunday, November 11

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Dr. Farhad Hafezi talks about protocols for corneal cross-linking applied to children with and without Down syndrome

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Our most valuable instrument: our hands

Winning at retina jeopardy
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TODAY’S NEWS FROM THE JOINT MEETING

FURTHER HIGHLIGHTS FROM SUBSPECIALTY DAY


TODAY’S NEWS FROM THE JOINT MEETING

Ophthalmology: The last bastion of hands-on care
Renowned physician and best-selling author Abraham Verghese, MD, MACP, opened the 2012 Joint Meeting today with a talk about where meaning resides in medicine—the human touch. It’s a powerful, old-fashioned tool that modern medicine is in danger of losing, he said.

Dr. Verghese is professor for the Theory and Practice of Medicine at Stanford University Medical School and senior associate chair of the Department of Internal Medicine. He is also the author of three best-selling books: two memoirs and a novel.

He began his discussion by examining Sir Luke Fildes’ famous painting, The Doctor (1891). It’s an iconic image that has influenced public perceptions of medicine over time and has been used to articulate different points of view about medical care.

Fildes was commissioned to create a piece that would “put on record the status of the doctor in our time.” He drew inspiration from the physician who cared for his oldest son. Despite the tragedy of his son’s death on Christmas Eve, Fildes was so impressed with the physician that he chose to depict “the physician in our time.”

In it, the doctor holds vigil by a gravely ill child’s bedside, with the worried parents in the background. None of the new medical instruments—stethoscope, thermometer, ophthalmoscope—of that Victorian era are pictured. It’s just light streaming in, with the doctor focusing singular attentiveness on the child. The public reception was overwhelming, and it was credited with elevating the medical profession.

When President Truman proposed a form of nationalized medical care, the American Medical Association weighed in with its opinion against the legislation by reproducing this image in countless brochures and posters bearing the slogan “Keep Politics out of This Picture.”

“It was a very successful campaign that has kept us from socialized medicine,” Dr. Verghese said, as it preyed on parents’ fears that Truman’s plan would mean their child might not get this kind of care.

In Britain, by contrast, the same image was used to celebrate the 50th anniversary of the National Health Service.

When asked about the painting, Fildes never mentioned the death of his child, Dr. Verghese said, but “spoke of the dawn breaking and the hope that comes to us all. I believe that it [the painting] is not about the doctor. It’s about you and me putting ourselves in the role of the sick child. What do I want? The attentiveness of the doctor. It speaks to the Samaritan instincts of medicine.”

If The Doctor were painted today, Dr. Verghese said he fears it would depict a doctor attentive to a computer screen instead of the ill child. “The patient in the bed has become an icon for the patient in the computer. I’ve taken heat from Silicon Valley for coining the term the iPatient. The iPatient is getting all the attention, while the patient in the bed is asking ‘Where the hell is everyone, when will I be informed?’ Medicine today has transformed the three-dimensional human being into a two-dimensional image.”

The danger of not being at the bedside is that you will lose the ability to diagnose the low-hanging fruit, and it represents the loss of an important ritual, he said.

“Rituals are about transformation. The ritual of one individual coming to another and telling them things they don’t tell their priest or rabbi, disrobing and then allowing people to touch them. That is a ritual of exceeding importance,” he said. “It preserves the personality of the patient and focuses on the body.”

“Ophthalmology is the last bastion of hands-on care,” Dr. Verghese said. “As you go out to the exhibit hall to look at the latest technology, remember that the finest instrument in your possession is your hand. The ability of the hand to heal is what we should be seeking.”

The need to preserve the meaning of medicine in the midst of the most extraordinary changes in health care since the 1960s was the common theme among all the Opening Session speakers, including Academy CEO David W. Parke II, MD.

Dr-Parke-vid_12_11_11At a time of rapid consolidation, EMR adoption and numerous quality of care initiatives, it’s important to measure your professional impact through the people you have helped and the lives you’ve changed, said Dr. Parke. “Remember the narratives—they are why we became doctors in the first place.”

“We all have those memories. Some are painful, but the personal relationships that generate these memories are some of the greatest gifts of practicing medicine and, for us, specifically ophthalmology, he said.

“The Academy will employ every available resource to advocate for our profession and our patients. We must commit ourselves to effecting reform so we make sure the business imperative doesn’t supersede the science or our patients. Remember the narratives.”—Susanne Medeiros

(Read more about Dr. Verghese in the current edition of Academy News, available at the Resource Center and online.)

Dr. Parke is an OMIC board member. Dr. Verghese has a financial interest in Random House and Knopf.

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Novel uses for femtosecond laser in cataract surgery
Surgeons who perform laser-assisted cataract surgery might be able to use the femtosecond laser’s Scheimpflug images as an objective, quantitative method to determine cataract density and guide their choices of phacoemulsification settings and lens-chopping technique, researchers reported today.

At an original papers session on femtosecond laser cataract surgery, Harvey S. Uy, MD, reported the results from a 52-eye study coauthored with Ronald Krueger, MD.

The researchers found a strong correlation between cataract density on the standard LOCS III grading scale and the density readings from high-resolution Scheimpflug images taken with the LensAR femtosecond laser, he said.

The images also provided highly detailed information about lens anatomy. These can reveal structural details that otherwise would have been unsuspected, allowing the surgeon to alter the phaco settings and nuclear disassembly technique, Dr. Uy said.—Linda Roach

Dr. Uy is a consultant to Alcon Laboratories and receives lecture fees from Alcon and LensAR.

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Oculoplastics symposium—from metals to molecules
In an overview of recent advances, speakers made it clear that oculoplastics isn’t what it used to be.

Blepharospasm. Botulinum toxin has dominated the field for two decades—“I haven’t frowned since 1987,” quipped Jean D. Carruthers, MD. The next phase: topical medications. He cited research on the RT001 molecule, which is showing effectiveness comparable to that of Botox. Research on injectable Botox continues, as recent findings of white matter abnormalities in the brain has raised concerns about long-term side effects.

Thyroid eye disease. Immunomodulatory therapy—specifically the drug rituximab—can prevent progression of Graves disease if used early enough, said Simeon A. Lauer, MD. “Don’t use it as a last resort.” However, he cautioned that many patients won’t need it, as thyroid eye disease is often self-limiting. In addition, he reminded the audience that rituximab is not FDA approved for this condition.

Periocular hemangioma. Propranolol has emerged as a highly effective treatment for periocular hemangiomas, said François M. Codère, MD. A flurry of positive research reports documenting high rates of regression have been published in just the past four to five years, he said, and his institution has developed a protocol for the use of the drug. He cautioned that much remains unknown, particularly optimal dosing and possible long-term side effects. He also recommended that surgeons develop a multidisciplinary team to work with patients.

Dacryocystorhinostomy. Endonasal dacryocystorhinostomy (DCR) is elbowing external DCR aside, thanks to such advantages as smaller incision size, minimal patient discomfort and limited bruising, said Nancy A. Tucker, MD. The success rate of endonasal DCR rivals that of external DCR, she said, adding that its slow acceptance probably owes more to the learning curve than to equipment expense, as most institutions have the equipment on hand for otolaryngology use.

Basal skin carcinoma. While topical 5-fluouracil (FU) remains a mainstay for basal cell carcinoma, the immunomodulator imiquimod (Aldara) is making inroads, said Timothy J. Sullivan, MBBS. Its advantages include use in cases of nodular and periocular disease; in contrast, 5-FU cannot be used for nodular disease, and there are no studies of its use for periocular disease. Side effects of imiquimod include keratitis and conjunctivitis, Dr. Sullivan said. In discussing the future of treatment, he noted, “I’ve spent a lot of time wondering why tropical fish don’t get sunburned,” and concluded, “The future is with the molecules.”

Enhancements. Surgical enhancements that were acceptable just a few years ago now look inappropriate to Robert A. Goldberg, MD. Treatment needs to be driven by questions such as “How do we age?” and “How do we lose tissue?” Given the current understanding that the aging process involves loss of volume and facial descent, Dr. Goldberg noted that he now prefers dermal fillers to surgical approaches, and he described his approach as an “additive rather than a subtractive” one. He also discussed the current fad of “stem cell facelifts” and characterized it as the “Wild West of stem cell treatment.” The field desperately needs careful, controlled trials, said Dr. Goldberg. He offered his summation of regenerative medicine: “future promise; current morass.”—Jean Shaw

Dr. Carruthers is a consultant for Allergan, Kythera and Merz. Drs. Codère, Lauer, Sullivan and Tucker report no related financial interests. Dr. Goldberg is a consultant to Merz.

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Best papers
During today’s Free Papers sessions, the expert panel moderating those presentations named the paper they rated most highly. These Best Papers are as follows:

  • Cataract Femtosecond session. High-Resolution Confocal Structured Images Guide Phacoemulsification Technique Selection During Laser-Assisted Cataract Surgery, presented by Harvey S. Uy, MD (event code PA003)
  • Glaucoma session. Topical Microdroplet Administration vs. Eyedropper for Delivering Eye Medication, presented by Tsontcho Ianchulev, MD (PA011)
  • Ocular Tumors and Pathology session. Long-term Follow-up of Patients Treated With Intra-arterial Cytoreductive Chemotherapy for Lacrimal Gland Adenoid Cystic Carcinoma, presented by Andrea N. Kossler, MD (PA024)
  • Orbit, Lacrimal, Plastic Surgery session. Long-term Success Rate of Endoscopic Laser-Assisted Dacryocystorhinostomy for Treatment of Nasolacrimal Duct Obstruction, presented by Jorge G. Camara, MD (PA029)
  • Refractive Surgery session. Screening for Ectasia Risk Using Placido and Tomographic Indices: Validation of an Artificial Intelligence Scoring System, presented by Alain Saad, MD (PA018)

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EHR vendors at the exhibition
Modernizing Medicine was omitted from the chart of EHR vendors that appeared in the Friday edition of Academy News. Visit Booth 2771 to learn about EMA Ophthalmology, their iPad-based electronic medical record system designed specifically for ophthalmic practices.

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Off to a running start
During this morning’s fun run, 333 meeting attendees raised more than a sweat—they also raised $16,805 for the Eye Bank Association of America. This year’s winner, Gary L. Legault, MD, finished the 5-km course in just under 17 minutes. The runners came from 24 countries and ranged in age from 11 to 82. The 27th annual Run for Vision was once again sponsored by Bausch + Lomb.

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The quotable ocularist
“My eye loss is probably one of the best things that ever happened to me,” said Walter Johnson, a monocular ocularist during today’s symposium, “How Does It Feel?—An Insider’s Perspective on Living with Anophthalmia.”

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FURTHER HIGHLIGHTS FROM SUBSPECIALTY DAY

Anterior uveitis: the top suspect
Recurrent nongranulomatous anterior uveitis is the most common form of anterior uveitis seen in the United States, representing 90 percent of the cases seen in community-based settings and 50 to 60 percent of those seen in referral settings, said Jennifer E. Thorne, MD, PhD, during Saturday’s Uveitis meeting.

Dr. Thorne presented an overview of a number of factors, including the following:

  • Course of disease. The course of anterior uveitis varies according to onset (sudden versus insidious); duration (limited versus persistent); and laterality (it can be unilateral, alternating unilateral, bilateral asynchronous or bilateral simultaneous).
  • Differential diagnosis. This includes associated systemic diseases, infectious etiologies (Lyme disease, strep, herpes and syphilis) and noninfectious etiologies.
  • Workup. This should include the “usual suspects,” as well as history-driven and region-specific tests (such as Lyme disease serology), she said.
  • Complications. Recurrence is a concern; in one study, 25 percent of patients had at least one recurrence over a 10-year period. Moreover, anterior uveitis may be the beginning of posterior disease. Other complications include macular edema, glaucoma and cataract.—Jean Shaw

Dr. Thorne is a consultant to Allergan and Xoma, and receives grant support from the National Eye Institute and Research to Prevent Blindness.

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Uncovered: X-ray therapy might help certain patients
Stereotactic radiotherapy for wet AMD produced positive overall results when combined with anti-VEGF injection therapy in a recent European trial. However, a new subgroup analysis has discovered some even better news buried in the study data—for a subset of AMD patients.

“This subgroup, consisting of about half of the total trial patients, had fewer injections and better visual acuity after 12 months if radiation was added to their anti-VEGF treatment,” said Timothy L. Jackson, PhD, FRCOphth, chief investigator for the large, multicenter INTREPID trial in Europe and a vitreoretinal specialist in London.

The responders were characterized at baseline by:

  • Significant fluid in the macula, with a median volume > 7.4 mm3 (50 percent of the study population).
  • Lesions no larger than 4 mm, the x-ray beam diameter (26 percent of the population).

Dr. Jackson shared the results Friday at the Retina Subspecialty Day meeting and said they support the need for further research.

Responders required half as many injections as controls (p = 0.001), and they gained 6.83 more letters of visual acuity than controls at 12 months (p = 0.0037), he said.

“In the era of anti-VEGF therapy, that is a big difference in acuity between the two groups,” Dr. Jackson said. “You seldom see figures that big these days.”

INTREPID was a prospective, double-masked, multicenter controlled clinical trial in 230 patients who had been treated previously with anti-VEGF injections. It was conducted at sites in five European nations.

Treatment consisted of a single x-ray dose of 16 Gy or 24 Gy from the iRay system (Oraya Therapeutics), plus a ranibizumab injection (Lucentis). Controls received a ranibizumab injection plus sham x-ray treatment. All patients were given additional intravitreal injections PRN over the subsequent year.—Linda Roach

Dr. Jackson is a consultant to and/or a recipient of grant support or lecture fees from Alimera, Bausch + Lomb, DORC International (Dutch Ophthalmic), NeoVista, Novartis, Oraya and Thrombogenics.

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Telemedicine can improve ROP screening
Telemedicine has the potential to get the United States out of an “ROP screening crunch,” but accomplishing this means taking advantage of our latest technologies. That was the central message from Darius M. Moshfeghi, MD, speaking at Retina Subspecialty Day on Friday in his lecture, “Update on the Study of Telemedicine for ROP.”

“We already know whom to screen and when to screen them,” he said, adding that, “blindness is preventable in 99 percent of babies who are receiving treatment for ROP.”

The problem is that changes in screening inclusion parameters mean that more babies should be examined—but there are fewer skilled screeners available than before. Thus, improving ROP screening methods has become increasingly important, said Dr. Moshfeghi.

Historically, ROP screening has been done via binocular indirect ophthalmoscopy (BIO). In skilled hands, BIO has some advantages, but it also has a number of disadvantages, including subjective interpretation and lack of reproducibility, said Dr. Moshfeghi. Moreover, many areas of the country lack an adequate number of screeners.

Telemedicine using fundus photography helps obviate the screener supply shortage by sending the images to centralized reading centers. It also offers the advantages of greater reproducibility and objectivity, and the images can be saved over time to follow the disease and treatment. But it’s not cheap and requires special equipment and training.

Still, Dr. Moshfeghi said, given that the SUNDROP study has shown 100 percent specificity and sensitivity in detecting treatment-warranted ROP, screening through telemedicine represents a great opportunity to address the crunch and, thus, reduce the incidence of blindness.

“At this present time it’s more important to screen than to develop new therapies,” he said.— Mark Simborg

Dr. Moshfeghi is a consultant to Genentech, Grand Legend Technology, InSitu Therapeutics, MyWhiteCoat, OcuBell, Oraya Therapeutics, Synergetics and Thrombogenics; has a patents/royalties interest in Convene, InSitu Therapeutics and VersaVision; and has an equity interest in Convene, Grand Legend Technology, InSitu Therapeutics, MyWhiteCoat, OcuBell, Oraya Therapeutics and VersaVision.

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Monday, November 12

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NEWS FROM THE JOINT MEETING

FURTHER HIGHLIGHTS FROM SUBSPECIALTY DAY


NEWS FROM THE JOINT MEETING

Cataract surgery to see significant reimbursement reduction
At a media briefing today, Michael X. Repka, MD, MBA, Academy medical director for Governmental Affairs, announced that the Centers for Medicare & Medicaid Services has implemented a physician fee schedule cut effective Jan. 1 of approximately 13.5 percent for cataract surgery. This estimate could change if Congress allows the SGR reduction to take effect.

That this surgery has become better and faster over the years plays a part in the new valuation. “For CMS, the value [of a procedure or service in the physician fee schedule] is driven in large part by time,” Dr. Repka said. Average time to perform a cataract surgery has dropped by about 30 percent in the eight years since the last CMS-mandated survey, said Dr. Repka. At the behest of CMS, the Academy and ASCRS surveyed a random sample of their members to collect these data for valuation of cataract surgery.

For further detail about this payment cut, visit AAO Eye on Advocacy in the Academy Community.

Dr. Repka receives support from the American Academy of Ophthalmology and the National Eye Institute.

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The Great Debate
What is the best anti-VEGF agent to treat wet AMD? How often do you treat? Is fluorescein angiography necessary to follow patients with AMD? What is the best way to treat diabetic macular edema? These were the questions some of the leading retina specialists debated this morning—with a large dose of humor.

Bevacizumab, ranibizumab or aflibercept? After a debate among David M. Brown, MD, Philip J. Rosenfeld, MD, PhD, and Jeffery S. Heier, MD, the audience weighed in. Bevacizumab just edged out ranibizumab, 36.5 percent to 35.5 percent.

With that question out of the way, the panelists turned to the best dosing regimen for anti-VEGF therapy. Lead investigator of the CATT trials, Daniel F. Martin, MD, argued that data from all the trials, including CATT, showed that monthly dosing, whether Lucentis or Avastin, achieved the best visual and anatomical results. Dr. Martin playfully dismissed the other regimen options as inferior, saying that PRN dosing actually stands for “progressive retinal necrosis,” and treat and extend is better described as “treat and pretend.”

“To those who say Lucentis is just a better drug, the trial data showed that all the differences [in visual acuity outcomes] were with the dosing. Outcomes with PRN Lucentis were no different than Avastin PRN. As soon as you back off, things get worse,” said Dr. Martin.

Arguing for PRN dosing was Anne E. Fung, MD. She agreed that the data favor monthly dosing, but the advantage is minimal—about a two-letter difference over two years of follow-up—and is not offset by the cost.

“Monthly dosing is really excessive treatment,” she said. “Studies show that the cost of treatment goes down dramatically when you use PRN.” Moreover, the data showed patients treated PRN had less geographic atrophy. Plus, more injections mean more risk.

Monthly treatment also runs the risk of overtreatment. “Your patients aren’t the same; PRN is personal.”

She then reminded Dr. Martin of remarks he made at previous meetings, saying he’d treat his grandmother with Avastin PRN, which prompted panel moderator Peter K. Kaiser, MD, to ask, “But does he like his grandmother?”

But the argument that won the day was that offered by Carl D. Regillo, MD, FACS, who advocated for treat and extend. Because AMD history and treatment response varies among patients, treatment regimens must be individualized.

“We are overtreating many of our patients. It’s expensive and inconvenient, and it poses increased risk, Dr. Regillo said. “PRN isn’t optimal because you have to wait for recurrence before you treat. It’s what brings down visual acuity results among PRN dosing groups. Treat and extend is the best of both worlds: It minimizes recurrence and maximizes outcomes at a minimum burden of expense.”—Susanne Medeiros

Dr. Fung is a consultant to Alcon, Genentech, Ista, Santen, Sequenom and Thrombogenics; and receives lecture fees and grant support from Genentech. Dr. Kaiser is a consultant to Alcon, ArcticDx, Bayer, Genentech, Novartis, Regeneron and SKS Ocular; he receives grant support from Genentech, Novartis and Regeneron; and has an equity interest in Regeneron. Dr. Martin reports no financial interest. Dr. Regillo is a consultant to and receives grant support from Alcon, Allergan, Genentech, GlaxoSmithKline, Novartis and QLT; and also receives grant support from Second Sight.

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How last week’s election will impact ophthalmology
Donald J. Cinotti, MD, chairman of OphthPAC, the Academy’s political action committee, discussed the outcome of the 2012 elections and the anticipated impact on medicine during today’s AMA Section Council Symposium.

Dr. Cinotti noted that more than 1,000 Super PACs spent over $631 million (as of Nov. 6) on the elections, far exceeding the $252 million spent by political parties or the $400 million spent by other outside groups, including PACs and unions. There will be significant analysis of the effects of these Super PACs on the elections.

Legislators must tackle a number of major fiscal issues during Congress’ lame duck session that begins this week. Dr. Cinotti said that legislators are likely to try to pass a temporary halt to the 27 percent Medicare physician pay cut scheduled to take effect Jan. 1, and another 2 percent cut caused by the federal sequestration process, leaving long-term solutions to the next Congress. Sequestration was triggered when Congress failed to identify $1.2 trillion in federal deficit savings last year. Legislative leaders of both parties have publicly commented that they must work together to find solutions to the impending fiscal cliff issues.

Dr. Cinotti stressed that support of the OphthPAC fund and member activism are essential to ensure that Congress stops the impending cuts. He challenged members to develop relationships with their legislators to enhance the Academy’s advocacy efforts to convince legislators to find permanent solutions. Learn more about OphthPAC online.—Kevin Walter

Dr. Cinotti reports no financial interest.

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Ophthalmologists discuss role of propranolol in hemangiomas
Ophthalmologists sparred over the treatment of infantile hemangiomas with propranolol during Sunday’s point-counterpoint session, “Controversies in Pediatric Ophthalmology and Orthoptics.”

Point: propranol. “My take-home message is just consider propranolol instead of oral steroids,” said Kathryn M. Haider, MD. She said that the rewards of propranolol can outweigh the risks and that prompt treatment is necessary to reduce the risk of amblyopia.

“Topical steroids are great, but they’re not for all lesions,” she said, noting that their use can lead to fat atrophy. We are at the end of the steroid era, she said. She described a case in which a 1-month-old infant was treated with steroids, but proptosis worsened. After treatment with propranolol for six days, the patient improved. “Clearly, propranolol is making a difference.”

However, Dr. Haider said, parents need to be counseled about the signs and symptoms of propranolol’s potential side effects of hypotension and hypoglycemia.

Counterpoint: steroids and surgery. Louise A. Mawn, MD, presented the case for considering other treatments. “What I would really like you to go home with today is that we may well have thrown out the baby with the bathwater,” she said. “Propranolol is absolutely fantastic,” she added. “There is only one problem—it doesn’t always work.”

Patients are more likely to develop strabismus or astigmatism without successful treatment at a young age. And some patients are treated with propranolol for up to six months, with limited results.

This, in turn, can limit vision in the affected eye and disrupt binocular vision, she said. After a child is 3 to 5 years old, the visual damage may not be reversible. The delay in or lack of effect with propranolol also can have a psychological effect on some parents and patients, she said.

She also asked ophthalmologists to consider the treatment’s potential side effects. “We’re subjecting otherwise completely normal children to a beta-blocker,” she said, noting that beta-adrenergic receptors are required to induce long-term memories and learning.

Dr. Mawn suggested keeping steroids in the armamentarium of treatment for infantile hemangioma, as well as surgery. “Propranolol should be used cautiously,” she said. It should be considered when there is a wide area of skin involvement or extensive orbital involvement.

However, she recommended halting treatment if a child is not showing a response.—Lori Roniger

Dr. Haider reports no related financial interests. Dr. Mawn receives grant support from the NIH and Research to Prevent Blindness.

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Phantom eye syndrome is common
Hui Bae Harold Lee, MD, FACS, gave a thought-provoking presentation on phantom eye syndrome after enucleation on Sunday. He described phantom eye syndrome as either a painless or painful sensation in the location of the amputated eye without a clear anatomical or postsurgical explanation.

He said that hallucinations can occur in up to 42 percent of enucleated patients, with 36 percent reporting flashing white lights, dots or shadows, and 5 percent experiencing complex hallucinations, faces, objects and scenes. A feeling of being able to see with both eyes is reported in 9 percent and photophobia in 2 percent. Some patients experience difficulty focusing the remaining eye.

Phantom eye pain has been described as cutting, penetrating, radiating or stinging. Up to one-third of patients have daily pain in the enucleated eye. Fifteen percent report pain several days a week. The pathophysiology of phantom eye syndrome remains unknown.—Lori Roniger

Dr. Lee reports no related financial interests.

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Malpractice: What gets you into trouble?
During the annual “OMIC Forum,” representatives of the Ophthalmic Mutual Insurance Company discussed the 10 highest-paying claims closed in 2011. Settlement amounts ranged from $250,000 to $1,000,000; most of the cases were settled out of court. Despite the diversity of the cases, some common risk management themes emerged.

Documentation. Inadequate, incomplete or inappropriate documentation was an issue in seven of the 10 cases. For instance, in one case, the medical record lacked documentation of the preoperative assessment, intraoperative monitoring, operative report, and communication between the physician and the nurses.

The OMIC panel offered some classic advice: Do not make any changes after the fact, do not pre-dictate operative notes and do not have multiple versions of office forms. Also, get older forms out of the office. They also noted that informed consent must cover all treatment options, both medical and surgical—and emphasized that it’s important to document both positive and negative patient responses and medical findings.

Telephone care. “Telephone care is a risky part of your practice,” said Anne Menke, RN, PhD. A personal examination—and one that’s conducted as soon as possible after surgery—is safest for patients, the panel members repeatedly emphasized. Whether you are talking to the patient, a resident or a specialist, relying on the telephone opens the door to opportunities for errors and misunderstandings.

Ms. Menke noted that OMIC has developed a template for after-hours/on-call telephone communication that should be part of the medical record. In addition, the form should be faxed to the physician for whom you are providing coverage and kept in a separate “after-hours” folder for 10 years.

Goals of treatment. Communicate early and often, the panel said. What are your goals with this treatment? What are the patient’s goals? You must make your goals clear to the patient, and you must understand the patient’s goals—and you must document the specifics of the conversation.

Informed refusal. A patient has the right to refuse care—and, from the risk management perspective, this must be adequately documented. Thus, the physician must ask the patient to clarify his or her reasons for refusal and lay out the potential consequences of the decision—and scrupulously document each step along the way.

Differential diagnosis. It’s important to maintain a high index of suspicion. In one case, which involved a possible diagnosis of giant cell arteritis (GCA), Ms. Menke reported that the plaintiff’s medical expert noted that he prioritized the differential diagnosis according to “probability, severity and treatability.” As GCA is severe and treatable, that should have been the leading diagnosis until it was excluded, the expert said.

This case also involved multiple examinations of a patient who denied having any of the common symptoms of GCA. “Patients are often poor historians,” Ms. Menke noted, and she recommended that physicians be sure to ask about past as well as present symptoms—and to document this process thoroughly.

Resources. More information is available from OMIC at their exhibit (Booth 1104) and online (www.omic.com). In addition, Ms. Menke recommended the Agency for Healthcare Research and Quality (www.ahrq.gov) for its “unexpected outcome” reporting modules.—Jean Shaw

Ms. Menke is employed by OMIC.

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Better low vision services require more awareness, education
Patients with low vision are only infrequently referred to rehabilitation services. Why? And how can we increase referrals?

That was the task set for Sunday’s “Vision Rehabilitation Education” symposium. The overall conclusion: Increasing referrals mainly comes down to increasing awareness, which requires education and outreach at all levels of the eye care continuum.

There are several reasons as to why patients don’t receive low vision rehabilitation. These include being in denial that they need it, lack of transportation and inadequate insurance coverage, said Joseph Fontenot, MD. He also suggested reasons why ophthalmologists might be reluctant to take on such patients: There’s no financial or emotional reward for them to do so, they’re too busy, and they don’t want to have to tell patients that there is no cure for their problem. Finally, there is no standard system for referral of low vision patients.

Dr. Fontenot urged attendees to take the following actions to improve awareness:

  • Post flyers in your practice about low vision rehab services
  • Go to church groups and other community organizations to let them know that such services are available
  • Encourage your technicians and nurses to learn about low vision and low vision referral
  • Use fundraisers to generate publicity

“The goal is for all low vision patients to be aware of their condition and referred to rehabilitation if desired,” he said. Mary Lou Jackson, MD, added that a key aspect of achieving this goal is educating residents.

Another speaker, Samuel Markowitz, MD, spoke about the importance of microperimetry for increasing low vision referrals. With its superior ability to gauge visual function, “Microperimetry offers an incredible bridge and opportunity between mainstream ophthalmology and the low vision rehab community of practitioners,” he said.—Mark Simborg

Drs. Fontenot and Markowitz report no financial interests. Dr. Jackson is a consultant for Humanware and has received grant support from Reader’s Digest.

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Hundreds become registered donors
At this year’s Joint Meeting, out on the western edge of the exhibit hall, the upbeat folks in Booth 136 are counting their successes one ophthalmologist at a time.

And by midday Monday, their “Are You a Donor?” campaign had inspired more than 300 Eye M.D.s and other passersby to sign up at the booth to become organ and tissue donors. The campaign was launched earlier this year by a Seattle eye bank, SightLife.“We’re asking ophthalmologists to be examples for their patients,” said Rusty Kelly, chief marketing officer. Physicians who say “yes” receive a big “I am a donor” button and an organ donation display kit for their offices, he said. If you are not able to visit the booth, you can sign up online.

In Chicago, “Are You a Donor?” is showing supportive videos recorded by Academy executive vice president and CEO David W. Parke II and the presidents of Bausch + Lomb, Allergan and Abbott Medical Optics. They can be seen at the booth and on the hotels’ meeting channel.—Linda Roach

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Best papers
During today’s Free Papers sessions, the expert panel moderating those presentations named the paper they rated most highly. These Best Papers are as follows:

  • Cornea, External Disease session—Part I. Theoretical, Experimental, and OCT Study of Factors Affecting Graft Apposition and Adhesion Strength in Descemet-Stripping Automated Endothelial Keratoplasty, by Romesh I. Angunawela, MBBS, (Maninder Bhogal was unable to attend) (event code PA035)
  • Cornea, External Disease session—Part II. A Randomized Double-Masked Placebo-Controlled Evaluation of Subconjunctival Bevacizumab for Recent Onset Corneal Neovascularization, by Kamaljit S. Balaggan, MBBS (PA044)
  • Intraocular Inflammation, Uveitis session. Intravitreal and Subconjunctival Sirolimus in Patients With Noninfectious Uveitis: One-Year Outcome of the Sirolimus as Therapeutic Approach to Uveitis (SAVE) Study, by Mohamed A. Ibrahim Ahmed, MBBCH (PA072)
  • Neuro-Ophthalmology session. Results not yet announced at time of press.
  • Retina, Vitreous session—Part I. Effects of Intravitreal Ranibizumab on Diabetic Retinopathy Severity: 36-Month Data from RISE and RIDE Trials, by Michael S. Ip, MD (PA054)
  • Retina, Vitreous session—Part II. Antibiotic Resistance of Ocular Surface Flora After Continued Use of Topical Antibiotics Following Intravitreal Injection, by Vivian T. Yin, MD (PA061)

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The quotable ophthalmologist
At an instruction course on Monday morning, Dan Z. Reinstein, MD, had this perspective to offer aspiring surgeons: “To be a great LASIK surgeon, you need to be someone who enjoys and takes pleasure in the perfection of repetition. Like a concert pianist or an airline pilot, you take pleasure in executing the perfect performance over and over again. But you’re ready for any situation which requires an alteration of your process.”

During the Spotlight on Cataracts session, Thomas A. Oetting, MD, MS, presented a video on intraoperative floppy iris syndrome that included the following rap lyrics: “Blame it on the Flomax, blame it on the Chang, wrote a big paper, blame it on the prostate, funny little gland. Blame it on the Flomax, iris got a billow, chamber getting shaky, prolapse is coming, we have been there before, watch out iris coming, someone gotta close the door.” This raised the question of whether lyrical ability should be considered during the Straatsma Award selection process.

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FURTHER HIGHLIGHTS FROM SUBSPECIALTY DAY

The benefits of intraoperative SD-OCT
Intraoperative spectral-domain OCT (SD-OCT) is useful. That was the conclusion of Sunil K. Srivastava, MD, in his presentation during the Retina meeting on Saturday. He said that feedback on surgical results can be available within a few minutes, rather than a few weeks, with intraoperative SD-OCT. And he joked that surgeons who work with fellows can find out, “What did that fellow just do to the macula?”

He said other advantages of intraoperative SD-OCT include that it can help in determining the surgical endpoint, as well as in discerning “when we haven’t done enough and need to adjust our surgical plan.” Other uses include detecting increased subretinal fluid after membrane peeling and identifying nonvisible membranes, tissue layers and changes to microstructure after surgical manipulation. “This is a great teaching tool,” he said.

However, the use of intraoperative OCT is limited, since it is currently performed with a handheld device. Intraoperative OCT is expected to be integrated into microscopes, Dr. Srivastava said. To that end, a prospective study using a prototype is being conducted at Duke University, and a Carl Zeiss Meditec prototype has been developed that integrates Cirrus HD-OCT with a surgical microscope.—Lori Roniger

Dr. Srivastava is a consultant for Bausch + Lomb and receives grant support from Allergan, Bausch + Lomb and Novartis Pharmaceuticals.

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Rethinking dry eye and ocular inflammation
Keratoconjunctivitis sicca, commonly known as dry eye, is a growing public health concern in the United States, said Esen Karamursel Akpek, MD, during Saturday’s Uveitis meeting. She outlined the following concerns:

  • Diagnosis. Dry eye can be difficult to diagnose, largely because of a lack of correlation between patient-reported symptoms and current clinical diagnostic tests.
  • Prevalence. Estimates vary, but the condition may affect up to one-third of adults in the United States.
  • Risk factors. These include increasing age, female gender, lifestyle factors (such as computer use), topical and systemic medications, and underlying systemic diseases.
  • Inflammatory issues. Ophthalmologists need to be aware of the connection between dry eye and Sjögren syndrome, Dr. Akpek said. Primary Sjögren syndrome is characterized by aqueous-deficient dry eye plus the symptoms of dry mouth, with reduced salivary secretion, in the presence of autoantibodies. Secondary Sjögren syndrome consists of these features plus those of an autoimmune connective tissue disease, with rheumatoid arthritis the likeliest suspect.

Dr. Akpek noted that, regardless of any identifiable risk factor, dry eye appears to be associated with ongoing ocular surface inflammation—and that this inflammation appears to be mediated by T-cell lymphocytes.—Jean Shaw

Dr. Akpek has received grant support from Alcon Laboratories and Allergan.

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Infective uveitis: Beware the big three
Herpes, syphilis and tuberculosis continue to present ophthalmologists with diagnostic and treatment challenges, said Amod K. Gupta, MBBS, on Saturday at the Uveitis meeting.

If these diseases are treated in a timely manner, he said, the outcome usually is good. However, to achieve this end, the clinician must maintain a high index of suspicion and an awareness of disease patterns.

Herpes. This is an often overlooked cause of uveitis. Herpetic anterior uveitis is characterized by a recurrent granulomatous iridocyclitis. Corneal scarring or active keratitis may occur. Posterior segment involvement may occur in the form of acute retinal necrosis or progressive outer retinal necrosis. “Acute retinal necrosis is one of the major emergencies,” Dr. Gupta said. Viruses commonly associated with this condition include the herpes simplex and herpes zoster viruses.

Syphilis. The “great masquerader” is back, Dr. Gupta said, with the incidence rising over the past decade in the United States, Canada and several European countries. Concomitant infection with the human immunodeficiency virus is likely, and ocular syphilis may be the presenting symptom of HIV infection.

As these patients frequently have neurosyphilis, their symptoms may include headache and nausea. With regard to uveitis, they may have anterior, intermediate, posterior or panuveitic forms of the disease.

Treatment is as for neurosyphilis. Prompt treatment usually preserves vision; delayed treatment may result in vision loss.

Tuberculosis. Diagnosis remains a significant challenge and should be considered when dealing with at-risk populations, Dr. Gupta said. Current diagnostic tests have limited sensitivity, and newer tests—particularly the use of real-time PCR and multitargeted PCR—are worth incorporating into the laboratory array. In addition, he recommended consulting an infectious disease expert.

Any part of the eye may be affected; common clinical signs include neuroretinitis, retinal vasculitis and chronic recurrent granulomatous anterior uveitis. Treatment involves antituberculosis medications.—Jean Shaw

Dr. Gupta reports no financial interests.

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