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Academy Live 2013

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 Annual Meeting. Look for it in your inbox or read it below this November.


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Friday, November 15

New Orleans welcomes thousands of eye surgeons today as the Academy’s Refractive Surgery and Retina Subspecialty Day meetings commence. Here are some highlights from today’s sessions.


Office-based vitrectomy: proceed with caution
In a pro/con session during this morning’s Retina meeting, Thomas M. Aaberg Jr, MD, and Steven T. Charles, MD, argued the merits of office-based vitrectomy.

Rationale for. Primary reasons for making the switch include cost, convenience, and control, Dr. Aaberg said. Proper patient and case selection is essential, he cautioned. With that as the starting point, “In every case we’ve performed, we’ve been able to achieve all of our surgical goals,” he added.

He noted that safety concerns (such as the lack of a specialized air filtration system and no anesthesiologist on site) are valid concerns and should play a role in patient selection. Because of these limitations, “We choose patients who are relatively healthy, able to communicate, and able to tolerate minimal sedation.”

Rationale against. In making his argument, Dr. Charles focused on the substantive associated risks. “One thing that concerns me is the notion of the ‘simple case,’” he said. Systemic medical risks are a significant concern, he pointed out. “Day in and day out, we have patients who were cleared by their primary care physicians and then suffer arrhythmias or diabetic complications in our center. Every week, we send patients back to their physicians or on to the ER.”

With regard to safety concerns, Dr. Charles highlighted the multiple advantages of the hospital setting. He asked, “Are you equipped? What are you going to do if you get in there and it turns out to be a different case than you anticipated?” He cited several tragic outcomes of office-based cases he was aware of, including a patient who went into anaphylactic shock from the fluorescein angiography and died, as the ambulatory surgery center involved had no defibrillator on site.

Audience vote. The audience agreed with Dr. Charles, with more than two-thirds voting that the time has not yet come for office-based vitrectomy.—Jean Shaw

Dr. Aaberg is a consultant for Synergetics and receives lecture fees from Allergan. Dr. Charles is a consultant for and has a patents/royalties interest in Alcon and Topcon Medical Systems.

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Meta-analysis suggests safety of phakic IOLs
At the Refractive Surgery meeting, Thomas Kohnen, MD, PhD, FEBO, presented a meta-analysis on the safety of phakic IOLs based on the findings of 20 papers. Although none were prospective randomized controlled trials, the studies provided promising findings regarding endothelial cell density loss and cataract formation.

Their results indicate that the main endothelial cell density loss after phakic IOL implantation occurs early on through the first postoperative year as a result of surgical trauma, at a rate of 3.5 percent, Dr. Kohnen said.

They also found that the absolute rate of cataract formation was 0.47 percent, with no evidence that new cataracts were due to phakic IOL implantation.

The 20 papers the investigators deemed adequate for inclusion in their meta-analysis were prospective studies written in English and included a total of 2,502 eyes of 1,825 patients.

Dr. Kohnen would like to see more prospective, long-term randomized controlled trials on cataract formation and endothelial cell density loss after phakic IOL implantation that include a sufficient number of eyes followed over the entire study.—Lori Roniger

Dr. Kohnen is a consultant for Alcon, Carl Zeiss Meditec, Rayner Intraocular Lenses, Schwind eye-tech-solutions; is a lecturer for Alcon, Bausch + Lomb, Carl Zeiss Meditec, Hoya, Rayner Intraocular Lenses, and Schwind eye-tech-solutions; and receives grant support from Alcon, Bausch + Lomb, Carl Zeiss Meditec, Hoya, Neoptics, Rayner Intraocular Lenses, and Schwind eye-tech-solutions.

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Retina report: selected study outcomes and a synopsis
A new addition to the Retina meeting—First-Time Results of Clinical Trials—presented results of some major trials. Anti-VEGF medications continue to be an area of research focus, with investigators presenting the outcomes of studies. Here’s an overview of selected findings:

Ranibizumab vs. bevacizumab—inject and extend. The Lucentis Compared to Avastin Study (LUCAS) is the first multicenter trial to compare ranibizumab and bevacizumab while employing an “inject-and-extend” protocol. One-year results from the two-year study indicate that the two anti-VEGF medications produced equivalent outcomes with regard to improvements in visual acuity (VA) and decreases in retinal thickness. Safety outcomes also were roughly equivalent, reported Karina Berg, MD.

All told, 432 patients with wet age-related macular degeneration were randomized to receive either ranibizumab or bevacizumab; 86 percent completed the one-year treatment period. There were slightly more thrombotic events noted with ranibizumab, with 4.6 percent of those in the ranibizumab cohort affected, versus 1.4 percent of those in the bevacizumab cohort. One case of pseudoendophthalmitis was noted in the bevacizumab group.

Topical anti-VEGF treatment. Retina subspecialists hoping to replace intravitreal injections of anti-VEGF medications with topical options may have to wait a bit longer. In the phase 2b Pazopanib Study, daily topical administration of the VEGF inhibitor pazopanib met one of the study’s primary objectives—maintenance of VA, compared with monthly and as-needed ranibizumab. However, the topical treatment did not displace 50 percent or more as-needed ranibizumab injections, which was the investigators’ minimal success criteria to demonstrate efficacy. Speaking for the Pazopanib Study Group, Karl G. Csaky, MD, said, “It is possible that unknown factors will limit the efficacy of anti-VEGF drops.”

Ranibizumab vs. bevacizumab—parsing the data. In a synopsis of five studies comparing ranibizumab and bevacizumab, Daniel F. Martin, MD, highlighted the studies’ common findings:

  • Visual acuity. The two drugs are equivalent for VA outcomes. “There is no difference” between the two, Dr. Martin said. “I think we’re done with this question.” Moreover, treatment on an as-needed basis produces excellent VA, Dr. Martin said.
  • Anatomical differences. Both drugs produce immediate results, but ranibizumab produces the greatest decrease in thickness and retinal fluid. “There’s no question that there are anatomical differences,” Dr. Martin said.
  • Geographic atrophy. Monthly dosing produces more geographic atrophy than does as-needed dosing. It’s possible that this effect is higher with ranibizumab.
  • Safety. There are no “compelling and consistent” differences with regard to safety outcomes between the two drugs, Dr. Martin said.

The studies Dr. Martin used in his analysis were CATT, IVAN, MANTA, GEAFAL, and BRAMD.—Jean Shaw

Dr. Berg is a consultant for Bayer Healthcare Pharmaceuticals. Dr. Csaky is a consultant for Acucela, Genentech, GlaxoSmithKline, Heidelberg Engineering, Isis Pharmaceuticals, Merck, Novartis Pharmaceuticals, Ophthotech, QLT Phototherapeutics, Roche Diagnostics, and Santen; receives lecture fees from Genentech; and receives grant support from Allergan, Genentech, and Iridex; and has equity ownership in Ophthotech. Dr. Martin reports no related financial disclosures.

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The pediatric retina: what to look for
The clinician who misses retinal pathology in a pediatric patient may well miss a critical opportunity to save a patient’s vision, said Philip J. Ferrone, MD.

There’s no question that young patients can present diagnostic challenges, particularly if they are uncooperative. However, in reviewing common retinal conditions seen in the pediatric population, Dr. Ferrone noted that excellent visual outcomes are achievable with early diagnosis and treatment.

Leading concerns. Retina specialists should have a high index of suspicion for the following seven time-sensitive, generally treatable pediatric conditions: retinopathy of prematurity; retinoblastoma; retinal detachment related to persistent fetal vasculature syndrome; progressive neovascular diseases such as familial exudative vitreoretinopathy (FEVR) and sickle cell disease; Coats disease; vitreous hemorrhage; and posttraumatic conditions, including retinal tears, retinal detachments, and macular holes.

The uncooperative child. In such cases, Dr. Ferrone said, the clinician should have a low threshold for examination under anesthesia (EUA), particularly if a peripheral depression exam of the retina is necessary.

Use of genetic testing. This can be helpful for some conditions (Stargardt disease, congenital retinoschisis, Best disease) but has limited value for others, notably FEVR.

Use of screening technologies. Diagnosis and treatment of peripheral vascular diseases may warrant the use of fluorescein angiography. If this is the case, the clinician can use the RetCam 130 degree lens in infants and young children during the EUA. For older, cooperative children, Optos may be used.

Dr. Ferrone also suggested that clinicians use 1) spectral-domain OCT to evaluate the macula for abnormalities, 2) fundus autofluorescence to evaluate for Stargardt disease, Best disease, and foveal hypoplasia, and 3) electroretinogram if rod or cone dysfunction is suspected.

Use of TORCH titers. This is appropriate for infants and young children with inflammation or retinal scarring.—Jean Shaw

Dr. Ferrone is a consultant for Allergan, Arctic DX, Bausch + Lomb, Genentech, and Regeneron; receives lecture fees from Allergan, Genentech, and Regeneron; and receives grant support from Alcon, Allergan, Genentech, and Regeneron; and has an equity ownership interest in Arctic DX.

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Refractive ranges established for investigative presbyopia-correcting corneal inlay
The Raindrop Near Vision Inlay from ReVision Optics has the CE Mark but is an investigational device in the United States. At Friday morning’s Refractive Surgery Subspecialty Day papers session, Roger F. Steinert, MD, spoke about his experience as a medical monitor for a study to determine the best refractive range for treatment with the presbyopia-correcting inlay. 

The hydrogel inlay is implanted at 150 µm. After implantation, Bowman’s layer and the anterior cornea remodel, taking a prolate shape.

The lens was implanted in 188 patients with uncorrected vision of –0.5 D to +1.5 D, and all patients achieved 20/25 acuity at near and intermediate. With regard to distance visual acuity, however, the subset of patients with –0.5 D to 0.0 D spherical error had a drop in distance visual acuity to below 20/25. “Hyperopes are at a slight advantage,” Dr. Steinert noted. “The sweet spot is +0.25 D to +1.5 D.”

He said that patient age had no significant impact on outcomes. There was a 2 percent removal rate, largely attributable to “unhappy optics” issues.—Patty Ames

Dr. Steinert is a consultant for Abbott Medical Optics (AMO), OptiMedica, ReVision Optics, and Wavetec; is a patent holder and/or receives royalties from Rhein Medical; and receives grant support from AMO.

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What’s your story?
The Story Wall is a new feature of the Annual Meeting. Each day, a new question will be posted and you can use the markers provided to give your answer. Friday’s question was, “What is #1 on your bucket list?” The answer that got the biggest laughs—“To stay out of the bucket!”

Tomorrow’s question will be, “What is your favorite restaurant in New Orleans?” Join the narrative by adding your answer to the Story Wall, which is located in Lobby A, opposite the Great Hall.

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The quotable ophthalmologist
“When you’re on the cutting edge, you get cut.” Robert Osher, MD, speaking on the potential safety issues of femto-assisted LASIK.

“We all have problems with diagnosing children, which is why so few of us do it,” said Philip J. Ferrone, MD.

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Guest Medical Editor:
William Trattler, MD

Managing Editor:
Chris McDonagh

Editors:
Patty Ames, Peggy Denny, and Susanne Medeiros

Writers:
Lori Roniger, Jean Shaw, and Mark Simborg


The articles in Academy Live come from events and presentations that took place during Subspecialty Day and the Annual Meeting of the Academy, and are not the product, opinion or position of the Academy unless explicitly stated to be so. The Academy does not endorse products, companies or organizations. The Academy disclaims all liability.

Questions? Comments? Email Chris McDonagh at cmcdonagh@aao.org.

©2013 American Academy of Ophthalmology. All rights reserved.

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Saturday, November 16

Highlights from the Friday and Saturday Subspecialty Day meetings.


Regional rates of visual field loss
Beware of using standard global measures to monitor focal defects, disease progression, and response to treatment, Joseph Caprioli, MD, FACS, cautioned in his American Glaucoma Society Lecture.

Dr. Caprioli and his team have developed a software system—and published a report of the technique used to create it—that can measure and predict rates of regional visual field (VF) decay.1 The system, which isolates faster and slower components of VF decay, can identify patients who are “fast progressors” and can be used to predict patterns of future VF loss.

In a study now in press, the investigators used the system to monitor the effect of trabeculectomy on VF progression. They found that trabeculectomy exerts differential effects on the two groups: Pretreatment “fast progression” areas show a reduction in their rate of progression, while pretreatment “slow progression” areas show a very slight increase in their rate of progression.

His take-home message: Global measures such as visual field index and mean deviation are not sensitive enough to catch the subtleties of focal defects and thus are of limited value in measuring the effects of glaucoma treatments.—Jean Shaw

1 Caprioli J et al. Invest Ophthalmol Vis Sci. 2011;52(7):4765-4773.

Dr. Caprioli reports no related financial interests.

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Femto vs. phaco: technology trumps tradition
In a mock trial, complete with Eric D. Donnenfeld, MD, as a bewigged judge, it was decided that phacoemulsification cataract surgery will inevitably be replaced by laser. But many cataract surgeons still hold a place in their hearts—and their offices—for phaco, at least until femtosecond technology improves and becomes less expensive.

The point/counterpoint debate, which took place during Friday’s Refractive Surgery meeting, considered three aspects of the two methods.

  • Refractive results. Femtosecond lasers provide better refractive results than phaco, but only with the recent development of arcuate incisions, decided “Judge” Donnenfeld.
  • Safety. While it’s hard to argue that laser refractive surgery isn’t safer, there are documented complications, such as posterior capsule tear and pupillary constriction.
  • Time and cost. Setup for femtosecond laser surgery is longer, but actual surgical time is shorter. Femtosecond technology costs far more, of course, making it prohibitively expensive in most developing countries.

In the end, Dr. Donnenfeld said, the choice is one that must be made by the patient using the informed advice of the surgeon. In that sense, there is no clear winner. However, looking at the bigger picture, Dr. Donnenfeld likened phaco to a beloved, but old, dog that still has its charms but will ultimately be replaced by a new exciting puppy.

“While phacoemulsification is still a wonderful procedure, that new puppy looks like it’s going to be taking over the house very soon.”—Mark Simborg

Dr. Donnenfeld is a consultant for Abbott Medical Optics, AcuFocus, Alcon, Allergan, AqueSys, Bausch + Lomb Surgical, CRST, Elenza, Glaukos, Kala, Katena Products, Lacripen, LenSx, Mati Pharmaceuticals, Mimetogen, Novabay, Odyssey, PRN, Tearlab, Truevision, and Wavetec; receives lecture fees from Abbott Medical Optics, Alcon , Allergan, Bausch + Lomb Surgical, and TLC Laser Eye Centers; has an equity ownership interest in Mati Pharmaceuticals, Strathspey Crown, TLC Laser Eye Centers, and Truevision; and receives grant support from Abbott Medical Optics, Alcon, Allergan, and Bausch + Lomb Surgical.

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Addressing the potential “epidemic” of herpes zoster
Evidence supports the increasing prevalence of herpes zoster (HZ), and combating it will require better research and treatment, said Elisabeth J. Cohen, MD, on Saturday at the Cornea meeting.

Dr. Cohen said that although HZ doesn’t fit the official definition of “epidemic,” since it’s not contagious, it is excessively prevalent, and all signs point to a continuing increase. A study conducted in Minnesota before the availability of the HZ vaccine showed an increase in annual incidence per 1,000 from 3.2 in 1996 to 4.1 in 2001. In a study of veterans from 2000 to 2007, the annual incidence per 1,000 people rose from 3.10 to 5.22.

Dr. Cohen noted that the trigger for most cases of HZ remains unknown, as does what distinguishes the one-third of immunocompetent patients who get HZ during their lifetime from the two-thirds who don’t.

Still, the HZ vaccine has proved to be safe and effective, reducing disease burden by 61 percent and incidence by 51 percent in immunocompetent veterans aged 60 years and older. However, underuse of the vaccine is a serious problem, with less than 16 percent of eligible people aged 60 years or older in the United States receiving it as of 2011.

Lack of physician recommendations is one of the main barriers to greater adoption of the vaccine. Increasing awareness among physicians, patients, and nurses, as well as the use of electronic medical records for vaccination reminders, will help overcome this barrier.—Mark Simborg

Dr. Cohen receives grant support from Merck.

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Propranolol changes the face of infantile hemangioma treatment
During a presentation on infantile hemangioma at Saturday’s Oculofacial Plastic Surgery meeting, Gregg T. Lueder, MD, discussed how treatment for the condition has substantially changed since a 2008 paper reported the rapid decrease of hemangioma size in two children given the drug for cardiomyopathy, as well as nine additional patients who experienced similar results.

That year, three studies on propranolol for hemangioma were published; that number ballooned to 122 by 2011. “It’s the most remarkable thing I’ve seen in terms of changing how we treat things,” he said.

Oral propranolol is not FDA approved for any pediatric indication. However, it has a 30-plus year history of use in pediatric cardiology. Dr. Lueder said that it has been remarkably effective for infantile hemangioma, has helped many patients avoid surgery, and has few side effects. The treatment protocol is 2 mg/kg/day for 12 months. There may be mild lesion regrowth upon cessation, which typically doesn’t require retreatment.

Timolol also has been used for infantile hemangioma, but its effectiveness is limited to superficial lesions, Dr. Lueder said.

Propranolol works for 98 percent of infantile hemangioma patients according to a recent review, Dr. Lueder said, emphasizing that the remaining 2 percent require other treatments, such as steroids or surgery. “Steroids are not quite dead,” he said.—Lori Roniger

Dr. Lueder reports no related financial interests.

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Dry eye patients: the multistep approach
When faced with a challenging dry eye patient, there are a number of key steps to take to ensure the best management and a happy patient, said Penny A. Asbell, MD, on Saturday at the Cornea Subspecialty Day. These steps are:

  • Listen: What is the complaint? What is the patient using? What therapies have been tried in the past and for how long?
  • Rule out the use of the preservative benzalkonium chloride (BAK).
  • Evaluate the patient for systemic diseases, including diabetes and Sjögren syndrome.
  • Use keratography to measure tear breakup time, redness, and meibomian gland dysfunction.
  • Examine the lids.
  • Stop the patient’s current eyedrops and treat with the appropriate combination of cyclosporine, topical low-dose steroids, Lacriserts, autologous serum, or scleral contact lenses.—Mark Simborg

Dr. Asbell is a consultant for Alcon, Bausch + Lomb Surgical, Merck, and Senju; receives lecture fees from Merck and Santen; and receives grant support from Alcon, Bausch + Lomb Surgical, and Pfizer.

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Pregnancy and glaucoma
Few studies have addressed the issue of treating glaucoma during pregnancy. What’s a clinician to do?

Martha M. Wright, MD, referred glaucoma specialists to the FDA’s classification system of drug safety during pregnancy.

  • Know the classifications. Brimonidine is the best choice among glaucoma medications; it is in class B (defined as “no evidence of risk in humans”). Most other glaucoma drugs are class C (defined as “risk cannot be ruled out”). Mitomycin C and 5-fluorouracil are class X and thus are contraindicated during pregnancy.
  • Know the impact on infants. Beta-blockers are actively secreted and concentrated in breast milk; as a result, infants of treated mothers should be monitored for apnea and bradycardia. Mothers who plan to nurse and are taking brimonidine should be taken off the drug at delivery, as brimonidine can cause apnea in infants, Dr. Wright said.
  • Plan ahead. It’s essential to talk with young female glaucoma patients before they become pregnant, Dr. Wright said. “And revisit the topic periodically and with any change in medication.”—Jean Shaw

Dr. Wright reports no related financial interests.

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Crosslinking with primary LASIK—two viewpoints
Should corneal crosslinking (CXL) be performed with primary LASIK? The answer to this question is no, argued Perry S. Binder, MD—at least not until research tips the risk-benefit ratio in favor doing so.

“The risk-benefit ratio for routine CXL for primary LASIK does not justify routine application because PRK can be used successfully for high-risk cases,” Dr. Binder said, during Friday morning’s Refractive Surgery meeting.

In his counterargument to Dr. Binder, John Marshall, PhD, from the United Kingdom, made the case for accelerated CXL after LASIK, a technique known as Lasik Xtra, which is not yet approved in the United States. He cited a prospective bilateral study of 24 patients in which there was no difference in refractive outcomes at three months in patients who underwent LASIK and those who underwent Lasik Xtra, he said.—Mark Simborg.

Dr. Binder is a consultant for Abbott Medical Optics, Accelerated Vision, AcuFocus, and Stroma; receives lecture fees from Abbott Medical Optics, Accelerated Vision, and AcuFocus; has equity ownership in Accelerated Vision, and AcuFocus; and has a patent/royalties interest in Stroma.

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Management of diabetic retinopathy: top 10 evidence-based recommendations
At the Retina meeting on Saturday, Dr. Jennifer K. Sun distilled down the top-line recommendations for managing diabetic retinopathy gleaned from recent clinical studies. You can view Dr. Sun’s entire presentation slides synchronized with audio through Meetings on Demand, which offers access to more than 200 hours of presentation videos from the 2013 Annual Meeting and Subspecialty Day. Purchase today and save $100 through Nov. 19, 2013.

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The quotable ophthalmologist
James C. Fleming, MD, on the difficulty of follow-up with some orbital fracture patients: “The knife and gun club doesn’t keep appointments.”

“I can tell we’re in a pediatric session. No one has had any significant financial disclosures all morning,” said Walter M. Fierson, MD.

On the learning curve associated with a new approach: “It’s like pancakes and babies—you throw the first ones out, and the rest are fine,” said Joseph Caprioli, MD, FACS, during his AGS Subspecialty Day Lecture.

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Guest Medical Editor:
Steven I. Rosenfeld, MD

Managing Editor:
Chris McDonagh

Editors:
Patty Ames, Peggy Denny, and Susanne Medeiros

Writers:
Lori Roniger, Jean Shaw, and Mark Simborg


The articles in Academy Live come from events and presentations that took place during Subspecialty Day and the Annual Meeting of the Academy, and are not the product, opinion or position of the Academy unless explicitly stated to be so. The Academy does not endorse products, companies or organizations. The Academy disclaims all liability.

Questions? Comments? Email Chris McDonagh at cmcdonagh@aao.org.

©2013 American Academy of Ophthalmology. All rights reserved.

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Sunday, November 17

TODAY’S NEWS FROM THE ANNUAL MEETING

FURTHER NEWS FROM SUBSPECIALTY DAY


TODAY’S NEWS FROM THE ANNUAL MEETING

The IRIS Registry: what it will do for you and your profession
The IRIS Registry (Intelligent Research in Sight) “offers a brilliant and important vehicle to better fulfill our obligations to our patients and to exert better control over our profession,” said David W. Parke II, MD, during the Academy CEO address at this morning’s Opening Session.

What is the IRIS Registry? It is a comprehensive, longitudinal, clinical data registry, said Dr. Parke. By giving you confidential, real-time, risk-adjusted portrayals of your practice processes and outcomes, it will promote practice improvement. It will also provide practices with access to incentive payments, it will support ABO's Maintenance of Certification (MOC IV) Part IV Performance Improvement Modules by automating the collection of data directly from electronic health records (EHRs), and it will facilitate large, registry-based clinical trials at a fraction of the time and cost.

Ensure Big Data is a friend, not a foe. The IRIS Registry will provide the profession with unassailable data on the value of ophthalmic services, said Dr. Parke. This will be critical in advocating for the profession, particularly as physician payment shifts from a volume-based approach to a more value-based one.

What it will mean for you. Later in the Opening Session, a panel discussion, moderated by Michael X. Repka, MD, went into more detail. The panel consisted of three ophthalmologists—Michael F. Chiang, MD, chair of the Academy Medical Information Technology Committee; Paul P. Lee, MD, JD, advisory member of the H. Dunbar Hoskins Jr. Center for Quality Eye Care; and William L. Rich III, MD, medical director of Academy Health Policy—plus David May, MD, PhD, chair of the board of governors of the American College of Cardiology, who discussed how registries have helped his specialty. Here are some highlights:

  • How will it impact your practice and its workflow? “It won’t take any additional time,” said Dr. May. “You’ll learn that your current workflow achieves the data acquisition.” And as soon as you start to get reports back, you’ll start making improvements, with the entire care team taking part, he said.
  • How will it impact the physician’s workflow? “You as a physician won’t have to do much, if any, extra work,” said Dr. Lee. The work is done in the background by a data integrator, which pulls the data from your EHR system.
  • What are the financial benefits for ophthalmologists? “If you look at the impact of meaningful use, PQRS, and value-based modifiers, we’re looking at ongoing 5 to 7 percent cuts in payments in Medicare,” said Dr. Rich. IRIS gives ophthalmologists the ability to capture the data required by those programs and could help them to avoid such penalties—about $300 million per year, said Dr. Rich, who will offer more details on Monday, 12:30-1:30 p.m., at the Technology Pavilion (Hall I1, Booth 5145).
  • Which EHR vendors sync with the IRIS Registry? In principle, the IRIS Registry should be able to sync with any EHR system, said Dr. Chiang. “So far, we’ve integrated with 12 different EHR systems at pilot sites, and this number keeps growing.”

Start the sign-up process today. Participation will be free for two years for the first 2,000 registrants. This opportunity is limited to U.S. Academy members and providers who work for them. You can start the sign-up process at the Academy Resource Center (Hall G, Booth 3239), where you can also ask for a demo. For more information, visit www.aao.org/irisregistry.—Chris McDonagh

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Academy launches AAO Virtual Meeting
Four sessions have already been streamed live from the meeting, including portions of Retina Subspecialty Day, the Opening Session, and The Great Debate: Glaucoma. It’s not too late to view these sessions and additional recorded content online by logging in and joining a meeting now.

Access the Virtual Meeting and use the Networking Lounge to engage with colleagues from around the world. Best of all, the AAO Virtual Meeting is free to everyone and will be available until mid-January.

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The structure-function “tipping point”
Contrary to what we’ve always believed—and what many studies have shown—structural changes actually occur at the same time as functional changes in glaucoma, said Joel S. Schuman, MD, at Sunday’s Robert N. Shaffer Lecture: Glaucoma Changes—Reality Bites.

These changes occur after a “tipping point” that marks the end of a short period of only structural changes, Dr. Schuman said, that are followed by a “floor” period, marked primarily by progression of visual field loss.

Long-term prospective studies have shown that a certain degree of structural loss occurs before functional loss, which has always been interpreted as meaning that “structural changes precede functional changes,” Dr. Schuman said. But even in very early glaucoma, people report a reduced quality of life.

“There must be something that we’re missing, maybe as an artifact of how we measure function in glaucoma,” Dr. Schuman said. “Current measurement technology limits our ability to detect functional abnormalities and changes early in glaucoma. And, similarly, it is difficult to measure structural change late in the disease.”

Dr. Schuman’s hypothesis on the structure-function relationship in glaucoma was validated in his recent and soon-to-be published 10-year study of 127 subjects who had glaucoma, were glaucoma suspects, or had healthy eyes.

“We now have longitudinal data validating the structure-function relationship and the concept of the tipping point,” he said.—Mark Simborg.

Dr. Schuman is a consultant for Carl Zeiss Meditec, Slack, and Vindico; has patent and/or royalty interests in Carl Zeiss Meditec; and receives grant support from the National Eye Institute.

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Raising more than a sweat
During this morning’s Run for Vision, 342 meeting attendees raised $17,190 for the Eye Bank Association of America. This year’s winner, Gautti Johannesson, MD, finished the 5-km course in 17:00 minutes. The runners came from 26 countries. The 28th annual Run for Vision was once again sponsored by Bausch + Lomb.

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The quotable ophthalmologist
“When you’re in New Orleans and hear, ‘I’m feeling nauseated,’ you have a different diagnosis to consider, but here we’re going to focus on ophthalmic problems,” Nathan M. Radcliffe, MD, at the beginning of his presentation during Sunday’s Spotlight on Ophthalmic Office Emergencies.

“What you write is a proxy for who you are,” Daniel M. Albert, MD, as quoted by Paul Lichter, MD, introducing Dr. Albert as 2013 Academy Laureate.

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FURTHER NEWS FROM SUBSPECIALTY DAY

Epi-off vs. epi-on CXL
Epithelium-off collagen crosslinking (CXL) is a well-studied, reliable procedure that consistently produces good results; epi-on CXL is newer but clearly has more potential in terms of both safety and efficacy. Those were the respective conclusions of Peter S. Hersh, MD, and Roy S. Rubinfeld, MA, MD, during Saturday’s Cornea meeting in their arguments for epi-off vs. epi-on crosslinking.

Why perform epi-off CXL? Dr. Hersh made several points in his argument for epi-off CXL, including:

  • It has been studied extensively since 1994, and numerous prospective, controlled clinical trials have shown that the long-term results are good in terms of topography, higher order aberrometry, and visual acuity.
  • Studies thus far on epi-on CXL have been short term, with conflicting results.
  • Epi-off CXL provides reliable riboflavin uptake with good absorption into the stroma.
  • With epi-on CXL, approximately 25 percent of the UV light never makes it to the stroma because it gets absorbed by the epithelium.

Why perform epi-on CXL? Dr. Rubinfeld countered by saying that epi-off CXL has a higher risk of adverse events, including corneal melting, haze, infections, and perforations, in addition to the well-documented problem of delayed corneal epithelial healing. Epi-on CXL also results in less discomfort and fewer treatment failures.—Mark Simborg

Dr. Hersch is a consultant for Avedro and receives grant support from Addition Technology and Synergeyes. Dr. Rubinfeld receives lecture fees from CurveRight and CXL Ophthalmics; has equity ownership in CurveRight, CXL Ophthalmics, and CXL USA; has patent and/or royalty interests in CXL Ophthalmics; and is an employee of CurveRight, CXL Ophthalmics, and CXL USA.

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Holding up a crystal ball to wet AMD therapy
Carmen A. Puliafito, MD, MBA, wrapped up Friday’s Retina meeting with a rundown of his predictions for the future of wet AMD therapy, including the following:

  • In the United States, Avastin will remain the leading drug for wet AMD for the next decade. It continues to be the least expensive effective treatment for wet AMD, and in the coming world of combination therapy, the use of two high-cost drugs will be an issue.
  • Blockade of VEGF will remain the core strategy for wet AMD treatment because inhibition of downstream VEGF appears vital in restoring retinal anatomy and vision. Blockage of other angiogenic targets, such as integrins, tyrosinase kinase, and bioactive lipids, have not been as effective in clinical trials.
  • The need for new anti-VEGF medications is limited, in part because there are already three highly effective drugs.
  • Within five years, combination therapy for wet AMD will be available. Clinical and experimental evidence now shows that there are two pathophysiologic pathways relevant to treatment: antileakage (VEGF) and antifibrosis (platelet-derived growth factor; PDGF).
  • New custom-engineered drugs with both anti-VEGF and anti-PDGF action will be studied.
  • The TB syringe and small-gauge needle will remain the leading intravitreal drug delivery system for at least the next decade. It is inexpensive, safe, effective, scalable, and ubiquitous; works with various drugs; and will work well in the early stages of combination drug therapy.—Lori Roniger

Dr. Puliafito holds patents and/or receives royalties related to Humphrey Zeiss.

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Use caution with generics
At Saturday’s Glaucoma meeting, Malik Y. Kahook, MD, noted that he prescribes generic glaucoma medications—in fact, more than 70 percent of his patients use generic drugs. But Dr. Kahook cautioned that generics present certain potential problems:

  • Lack of equivalency. Generic formulations may not contain the stated amount of active drug.1 Problems have particularly been noted with generics manufactured in India, which are now available in the United States.
  • Packaging problems. Generic bottle cap color and shape, bottle stiffness, bottle tips, and package inserts remain problematic. He cited an instance in which the bottle tip required piercing.
  • Clinical pearls. “In vitro is not in vivo,” Dr. Kahook said. When he shifts a patient from a branded medication to a generic, he has the patient return to the clinic sooner than normal. Patients also are encouraged to bring all of their medication bottles with them.
  • Regulatory pearls. The burden of tracking and reporting problems is “on the physician, not on the FDA,” Dr. Kahook said.—Jean Shaw

1 Kahook MY et al. Curr Eye Res. 2012;37(2):101-108.

Dr. Kahook is a consultant for Aerie, Alcon, Allergan, ClarVista Medical, Genentech, Glaukos, Ivantis, Merck, Shape Ophthalmics, and Valeant; receives lecture fees from Alcon and Allergan; has an equity ownership interest in Innovative Laser Solutions, Shape Ophthalmics, and ShapeTech; has a patents/royalties interest in Abbott Medical Optics, ClarVista Medical, Innovative Laser Solutions, Shape Ophthalmics, and ShapeTech; and receives grant support from Abbott Medical Optics, Alcon, Allergan, Genentech, Glaukos, Merck, and Regeneron.

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Guest Medical Editor:
Arun D. Singh, MD

Managing Editor:
Chris McDonagh

Editors:
Patty Ames, Peggy Denny, and Susanne Medeiros

Writers:
Lori Roniger, Jean Shaw, and Mark Simborg


The articles in Academy Live come from events and presentations that took place during Subspecialty Day and the Annual Meeting of the Academy, and are not the product, opinion or position of the Academy unless explicitly stated to be so. The Academy does not endorse products, companies or organizations. The Academy disclaims all liability.

Questions? Comments? Email Chris McDonagh at cmcdonagh@aao.org.

©2013 American Academy of Ophthalmology. All rights reserved.

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Monday, November 18

NEWS FROM THE ANNUAL MEETING


NEWS FROM THE ANNUAL MEETING

A new era for BRVO treatment
Tremendous recent advancements are changing the face of treatment for branch retinal vein occlusion, said Julia A. Haller, MD. “I would argue that our level of sophistication has increased not only on the pharmacologic side but also on the laser side. We have a panoply of options that we didn’t used to have,” said Dr. Haller, speaking on Monday during the Changing Paradigms in the Management of Venous Occlusive Disease symposium.

We’ve come a long way since the seminal study on grid coagulation for branch vein occlusion was published in the American Journal of Ophthalmology in 1984, said Dr. Haller. “I’m looking out there, and some of you were not even born when this study came out.”

Not much changed from that time until 2009, she said, when the SCORE study on triamcinolone was published. Dexamethasone and ranibizumab were next; and, just recently, the VIBRANT study showed good outcomes with aflibercept compared with laser treatment.

“We’re also talking about timing of treatment,” Dr. Haller said. “That’s something that we didn’t really think was an issue in the past.”

Another option is combination therapy. At least one study has suggested that combination therapy can improve visual acuity compared with monotherapy. “This is something I encourage everyone to start working on because we need more information about that approach,” Dr. Haller said.—Mark Simborg

(Further reading: See Untangling RVO in the November EyeNet Magazine.)

Dr. Haller is a consultant for Advanced Cell Technology, Allergan, Genentech, Merck, Regeneron, and Thrombogenics; and has an equity ownership interest in OptiMedica.

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Pearls from today’s Spotlight on Cataract Complications
It was another packed Spotlight Session, led by David F. Chang, MD, and William J. Fishkind, MD. A total of 18 cases were offered, with the presenters discussing what went wrong and how they recovered.

The full Cataract Spotlight Session, with comments from panelists and the results of audience voting, will be printed in the March 2014 EyeNet Magazine. In the interim, here are some clinical pearls drawn from some hair-raising cases.

  • Above all, keep calm. As panelist Ehud I. Assia, MD, put it, “Relax, take a deep breath, count to 10, and continue with surgery. Most of the problems come when you panic.” And Brian C. Little, MD, noted that disasters will call on surgeons’ cognitive skills. “Stay calm, keep rational, keep a calm voice, and work out what’s going on.”
  • Rare doesn’t equal never. As Terry Kim, MD, put it, “It might be rare, but that doesn’t mean it won’t happen to you.”
  • You need a plan. Have a backup plan in place before you start surgery. If something can go wrong, it often will.
  • Don’t take anything for granted. Whether it’s a matter of heeding basic safety concerns, staying fully mindful and present throughout the entire case, or taking one’s time during a difficult case, several presenters reminded the audience that their cases illustrated the basic mandate, “Don’t let down your guard.”—Jean Shaw

Dr. Assia is a consultant for Bio Technology General and Hanita Lenses and has an equity ownership interest in APX Ophthalmology. Dr. Kim is a consultant for Alcon, Bausch + Lomb, Ivantis, Ocular Systems, Ocular Therapeutix, Omerus, PowerVision, and SARCode Bioscience; receives lecture fees from Alcon and Bausch +Lomb; and has equity ownership in Ocular Therapeutix and PowerVision. Dr. Little is a consultant and receives lecture fees from Bausch + Lomb and has patent/royalty interests in Eyemovies.

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25 years of the JCRS Consultation Section
In his Charles D. Kelman Lecture, Samuel Masket, MD, took the long view, offering up a selection of cases from the Journal of Cataract & Refractive Surgery’s Consultation Section. Dr. Masket has served as editor of this section for 25 years, and the cases he selected illustrated the differences—and, in some instances, the similarities—in management strategies over that time period.

In introducing his lecture, Dr. Masket commented, “Dr. Kelman really solved the impossible, and he ushered in a new era of technology explosion in anterior segment surgery.” The cases that Dr. Masket presented reflect several of those technological changes, from phacoemulsification with a large incision to the investigational use of artificial iris devices and the potential use of the femtosecond laser.

Dr. Masket thanked the cataract surgeons in the audience who have either contributed cases or evaluated them over the years and encouraged those who have yet to do so to “join the conversation.”—Jean Shaw

Dr. Masket is a consultant for Alcon, Haag-Streit, Ocular Therapeutix, PowerVision, and WaveTec Vision Systems; receives lecture fees from Alcon; has equity ownership in Ocular Therapeutix; has patent/royalty interests in Haag-Streit; and receives grant support from Accutome.  

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Lessons learned from blasts in Boston and Texas
A riveting symposium on blast eye injuries included presentations from ophthalmologists involved with the response to the explosions that occurred in April of this year at the Boston Marathon finish line and at a West, Texas, fertilizer company, as well as presenters serving in war zones. Here’s what you should know about the U.S. incidents.

Patterns of injury. Allen B. Thach, MD, explained that people closer to the center of a blast can sustain thermal eye injuries, while eye injuries to those farther away can involve glass, debris, and wind. The proportion of injuries that are eye related increases farther from the blast.

Twenty-two (approximately 9 percent) of the people injured at the Boston blast required an ophthalmology consult, four of whom were children, said Yoshihiro Yonekawa, MD, a Harvard ophthalmology resident on call at the time of the blasts.

Among those injured in Texas, 3.7 percent required eye surgery. A large number of eye injuries were in children, and they fared better than did adults, who were more likely to undergo enucleation, said Henry Hacker, MD.

Fifty-five percent of the ophthalmic injuries in Boston were periocular, 32 percent were anterior segment, 9 percent were posterior segment, and 5 percent were open globe. In contrast, most of the Texas eye injuries that required surgical repair were open globe.

Mass trauma can happen anywhere. The panelists provided the following take-home points:

  • “If an incident like this happens in your town, you need to be ready and waiting for eye injuries,” said Jorge G. Arroyo, MD, who spoke about the response in Boston. “Hospital-based and citywide planning will certainly make an impact in the future.”
  • Plan for medical infrastructure failure, such as when the Texas explosion took out the local ambulance and helicopter.
  • “Ophthalmologists need to keep up their trauma skills,” said Robert A. Mazzoli, MD.
  • “You will feel a lot more anxiety than you ever imagined,” said Matthew F. Gardiner, MD, who was involved with the response in Boston and had heard rumors of “busloads of open-globe patients coming.” (These never materialized.) “Keeping staff cool is very essential,” he added.
  • Expect 10 to 20 percent of people injured in a blast to have eye injuries, said Dr. Mazzoli. And be prepared for polytrauma, including ocular polytrauma, in this setting, he added.
  • “Children are especially vulnerable to injury in disasters,” said Dr. Hacker. “Make sure to take a look at their eyes,” said Ankoor S. Shah, MD, PhD, who was involved with the Boston blast response.
  • Visual acuity may be normal, but patients can have traumatic optic neuropathy and other problems, Dr. Mazzoli said.
  • Eye shields are used in 39 percent of eye injuries in the military, compared with none following the Boston blast and some patients in Texas.—Lori Roniger

Drs. Arroyo, Gardiner, Hacker, Mazzoli, Thach, and Yonekawa report no related financial interest. Dr. Shah has an equity ownership interest in Medtronic and Pfizer.

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A red eye walks into an ophthalmologist’s office
A Spotlight Session on Sunday focused on what to do when ophthalmic emergencies appear in your office. Here’s one example.

Red eye after cataract surgery. “The thing we’re always concerned about, of course, is endophthalmitis,” which typically occurs more than 24 hours after surgery, said Paul Hahn, MD, PhD. The differential diagnosis is broad and includes retained lens matter, postop iritis, postsurgical irritation, and toxic anterior segment syndrome.

He said it’s important to know the Endophthalmitis Vitrectomy Study guidelines, which apply only to endophthalmitis after cataract extraction and IOL implantation, although most ophthalmologists don’t follow them strictly. Dr. Hahn said he injects intravitreal vancomycin 1 mg/0.1 mL and ceftazidine 2.25 mg/0.1 mL and administers a fourth-generation fluoroquinolone or fortified antibiotics topically.—Lori Roniger

Dr. Hahn reports no related financial interests.

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

  • Cataract (Part 1). IOL Calculations in Post–Laser Vision Correction Eyes Undergoing Cataract Surgery Using Multiple Methods, presented by Samuel Masket, MD (event code PA008)
  • Cataract (Part 2). Localized Opacification of Hydrophilic Acrylic IOLs After Procedures Using Intracameral Injection of Air/Gas, presented by Liliana Werner, MD, PhD (PA015)
  • Cornea, External disease (Part 1). Prospective, Randomized Comparison of Topical Prednisolone Acetate 1% vs. Fluorometholone After Endothelial Keratoplasty, presented by Marianne O. Price, PhD (PA043)
  • Cornea, External disease (Part 2). Does Fuchs Endothelial Dystrophy Exist? presented by Martin Dirisamer, MD (PA049)
  • Intraocular Inflammation, Uveitis. Wide-Field Imaging Findings of Patients With Susac Syndrome, presented by Sunil K. Srivastava, MD (PA011)
  • Ocular Tumors and Pathology. Significance of Measuring Immune Mediators for Differentiating Malignant From Benign Pigmented Intraocular Tumors, presented by Yoshihiko Usui, MD (PA025)
  • Orbit, Lacrimal, Plastic Surgery. Are We There Yet? The Journey of Fluorine Deoxyglucose Positron Emission Tomography in the Staging of Ocular Adnexal Lymphoproliferative Disease, presented by James English, BSMT, MBBS (PA026)
  • Pediatric Ophthalmology, Strabismus. A Cost-Effectiveness Comparison of Bevacizumab (Avastin) and Laser for Treatment of Retinopathy of Prematurity, presented by Michael J. Geske, MD (PA053)
  • Refractive Surgery. Preliminary 1-Year Results of LASIK vs. Contact Lens Patient Satisfaction Survey, presented by Francis W. Price Jr., MD (PA031)
  • Retina, Vitreous (Monday session). Intravitreal VEGF Levels in Proliferative Vascular Retinopathies Strongly Correlate With the Extent of Capillary Nonperfusion Noted on Wide-angle Angiography, presented by K.V. Chalam, MD, PhD (PA059)

Tuesday’s program features a Glaucoma session (8:30-11:30 a.m. in Room 255) and a Retina, Vitreous session (10 a.m.-noon in Room 271).

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The quotable ophthalmologist
On a trip to China, Samuel Masket, MD, was forced to make a bold sartorial statement, reminisced William J. Fishkind, MD, while introducing Dr. Masket as this year’s Charles D. Kelman Lecturer. “There are two kinds of luggage: carry-on and lost,” said Dr. Fishkind, explaining Dr. Masket’s choice of scrubs and sandals.

Spoken at the podium during today’s Spotlight on Cataract Complications:

  • “One haptic is in the bag; the other is in haptic heaven,” said Richard J. Mackool, MD
  • “Every time we inject, we have a potential lethal missile in our hands. I was lucky,” said Robert H. Osher, MD
  • “Every step that any surgeon takes is controlled injury,” said Kirk H. Packo, MD, commenting on Dr. Osher’s case.

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Guest Medical Editor:
Kimberly A. Drenser, MD, PhD

Managing Editor:
Chris McDonagh

Editors:
Patty Ames, Peggy Denny, and Susanne Medeiros

Writers:
Lori Roniger, Jean Shaw, and Mark Simborg


The articles in Academy Live come from events and presentations that took place during Subspecialty Day and the Annual Meeting of the Academy, and are not the product, opinion or position of the Academy unless explicitly stated to be so. The Academy does not endorse products, companies or organizations. The Academy disclaims all liability.

Questions? Comments? Email Chris McDonagh at cmcdonagh@aao.org.

©2013 American Academy of Ophthalmology. All rights reserved.

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