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    Academy Live 2014

    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 AAO 2014. Look for it in your inbox and read it below later this month.

    Sen. Rand Paul (R-Ky.) at AAO 2014.
    Sen. Rand Paul (R-Ky.) at AAO 2014. Read EyeNet’s profile of the senator and hear him speak during Monday’s ACA symposium (8:00-10:30 a.m.) in Room S406a.
    Kirk Packo as Sir Isaac Newton in a Surgical Debate on vitrectomy duty cycle at #aao2014.
    Kirk Packo as Sir Isaac Newton in a Surgical Debate on vitrectomy duty cycle at #aao2014.

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    Friday, October 17

    Chicago welcomes thousands of ophthalmologists today as the Academy’s Refractive Surgery and Retina Subspecialty Day meetings commence. News from today includes the following:

    Ebola the Topic of New Symposium on Sunday
    The first cases of Ebola in the United States have triggered a media storm. Unfortunately, not all of the commentary has been medically accurate.

    To help clarify the issues, the Academy added a new session to the program—Ebola Virus, which takes place on Sunday, 12:45-1:45 p.m., in Room E450. This session is not listed in the Final Program.

    The speaker will be Gordon M. Trenholme, MD, an infectious disease specialist at Rush University Medical Center, which—according to recent reports—the CDC may soon designate as the treatment center for any possible Ebola cases in the Chicago area. Dr. Trenholme is the James Lowenstine Professor of Medicine and the director of the Division of Infectious Disease at Rush University Medical Center in Chicago. 

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    Posterior Uveal Melanoma Is Front and Center of Schepens Lecture
    Jerry A. Shields, MD, presented the 2014 Charles L. Schepens, MD, Lecture—“Management of Posterior Uveal Melanoma: Past, Present, and Future”—based on his more than 40 years of experience at Wills Eye Institute.

    Past. In the 1970s, enucleation was the undisputed tactic for uveal melanomas—until an unexpected rise in postenucleation mortality rates revealed that enucleation itself can lead to metastasis. This led to the development of methods to decrease metastasis during enucleation as well as strategies for avoiding enucleation altogether, including laser photocoagulation and radiotherapy.

    Present. Today there are several methods for managing uveal melanomas, including transpupillary thermotherapy (TTT), but radiotherapy has emerged as the most common method. In recent developments, plaque brachytherapy has been combined with anti-VEGF, TTT, and panretinal photocoagulation to minimize vascular complication associated with radiation.

    A key question today, Dr. Shields said, is whether to wait or not to wait. Should we just treat all choroidal nevi prophylactically? No, he said. But, at most centers, a trend toward earlier treatment has emerged in recent years, based on the identification of risk factors for metastasis.

    Future. The future of melanoma management, Dr. Shields said, will involve a collaboration between the ophthalmologist, the oncologist, and the researcher. The ophthalmologist will be responsible for the earliest detection possible and relevant multimodal imaging, the oncologist will identify patient-specific genetic mutations and molecular pathway defects in order to administer better-targeted therapies, and the researcher will explore novel therapeutic options in animal models of the disease.

    “We’ve come a long way since the days of enucleating the eye and hoping for the best,” Dr. Shields said. “With earlier recognition and new systemic therapies in collaboration with our other medical specialists, we may be seeing better treatment in the future.”—Mark Simborg

    Dr. Shields reports no related financial disclosures.

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    OIS@AAO—Eyes in Space: Call for Research
    What happens to eyes in space? As astronauts are exposed to microgravity for longer periods of time, they are more likely to develop visual impairment and elevated intracranial pressure (VIIP) syndrome, said Dorit B. Donoviel, PhD, at the sixth annual Ophthalmology Innovation Summit @ AAO on Thursday.

    Symptoms and risks. VIIP is characterized by papilledema (grades 1-3), globe flattening, increased optic nerve sheath diameter, a hyperopic shift of +0.5 D to +1.75 D, choroidal folds, cotton-wool spots, and scotoma. More than 14 astronauts now have VIIP syndrome, and it appears that male astronauts are at greater risk than their female counterparts for papilledema, Dr. Donoviel said.

    Diagnostic difficulties. One of thechallenges in protecting astronauts’ eyes is a lack of dependable diagnostic testing, as standard Earth-based technologies have proved unreliable in the unusual conditions encountered in space travel.

    Research needed. Under the “Vision for Mars” program, the Space Medical and Related Technologies Commercial Assistance Program (Smartcap) initiative will award at least three research grants of $100,000 to $250,000 each by March 2015.

    Research is needed in the following areas:
    • Determining refraction in space
    • Testing visual field in space
    • Developing an easier and more accurate way to measure intraocular pressure in space
    • Measuring scleral thickness at the posterior pole
    • Developing techniques to image the retina and other vasculature
    • Differentiating benign from harmful disc edema
    • Estimating translaminar pressure across the lamina cribrosa
    Grant deadline. Applications are due by Dec. 4, 2014; for more information, seewww.smartcap.org.—Jean Shaw

    Dr. Donoviel is employed by the National Space Biomedical Research Institute.

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    Recommended Workup for RVO
    When is it necessary to work up a patient with retinal vein occlusion (RVO)—and what tests should you order?

    RVO is a complication of atherosclerosis, said J. Michael Jumper, MD, and risk factors include hypertension, hyperlipidemia, and diabetes. As for age, Dr. Jumper reminded audience members that “RVO is not just a disease of the elderly.” In fact, in one study, nearly half of patients were age 65 or younger.
    • Risk factors. Every patient who has an RVO should be thoroughly evaluated, particularly with regard to atherosclerotic risk factors and hypercoaguable risk factors (such as hyperhomocysteinemia and increased fibrinogen levels). Family history should be taken into account.
    • Standard testing. Blood pressure should be checked—and this should include an at-home patient log, as nocturnal hypotension can be an issue. Additional testing should include a lipid profile, blood glucose, and hemoglobin A1c.
    • Thrombophilia testing. This is rarely necessary, except in select patients, Dr. Jumper said. “The issue is, what will you do with the results? Either you’re going to offer anticoagulation or not.” But anticoagulation therapy may have limited effects on recanalization of affected tissue—and may have harmful effects on neural tissue.—Jean Shaw
    Dr. Jumper reports no related financial interests.

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    Wide-Field Imaging Makes Inroads in Pediatrics
    Although the RetCam remains the workhorse technology for pediatric imaging, wide-field imaging—including fundus photography and fluorescein angiography (FA)—is making significant inroads, particularly in monitoring patients with retinopathy of prematurity (ROP), said Antonio Capone Jr., MD.

    Wide-field imaging is now a “core technology for management of ROP, from infancy through adulthood,” Dr. Capone said. It also can be used for familial exudative vitreoretinopathy (FEVR), persistent fetal vasculature syndrome, and Coats disease.

    Benefits. Wide-field imaging is useful for tracking the extent of disease and activity, designing targeted treatment, and following patients longitudinally, Dr. Capone said. It also can be used to quickly screen asymptomatic relatives of patients with FEVR.

    Cautions. As this is a new technology, the full range of normal and abnormal peripheral findings have yet to be characterized. Thus, care is required in reaching conclusions, Dr. Capone cautioned. “Peripheral FA features should not be overinterpreted.”—Jean Shaw

    Dr. Capone has equity ownership and patents/royalty interests in FocusROP.

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    Universal Screening for Pediatric Eye Disease
    “Universal screening is an emerging tool and technology for pediatric eye disease and pathology that will likely see greater expansion throughout the developed world in the near future,” said Darius M. Moshfeghi, MD.

    And its applications extend well beyond retinopathy of prematurity (ROP). “Many children in the United States have their first formal eye screening at age 5—and by then, it’s often too late to have any impact on the progression of amblyopia,” Dr. Moshfeghi said. “That’s why the rate of amblyopia has held steady.”

    In the Newborn Eye Screen Testing (NEST) study, Dr. Moshfeghi and his colleagues have developed a screening protocol and telemedicine network, with the goal of identifying all perinatal cases of preventable blindness by screening newborns within 48 hours of birth. They found that universal screening is an effective tool for identifying retinal hemorrhages, with as many as 20 percent of infants affected. “Fortunately, most hemorrhages are gone within two weeks” after birth, Dr. Moshfeghi said. Longitudinal follow-up—including tracking amblyopia and strabismus—is planned.

    A critical note with regard to the NEST study: There was little agreement between pediatricians’ assessment of the infants’ eyes and the findings yielded by imaging.—Jean Shaw

    Dr. Moshfeghi is a consultant for Genentech and Synergetics and is a consultant for and has an equity ownership interest in Grand Legend Technology, Oraya Therapeutics, and Visunex.

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    LASIK vs. Contact Lenses
    Marianne O. Price, PhD, reported preliminary results of a large, ongoing treatment satisfaction study that compared LASIK patients with contact lens wearers. She noted that LASIK patients experienced improvements in night-driving vision compared with baseline and that better dry eye treatments were needed with all forms of vision correction.

    Dr. Price explained that it was more appropriate to compare LASIK patients with contact lens wearers than against those with “perfect eyes” because both LASIK and contact lenses entail some risk and provide better cosmetic and functional results than spectacles in correcting refractive error. Further, the researchers looked both at patients who had LASIK after using contact lenses and those who had LASIK after using spectacles. 

    The researchers surveyed patients at baseline and one and two years later (832 responses at two years, representing 66 percent of the original study group) and found that satisfaction rates were high with both LASIK and contact lenses. Among those who had LASIK, around 40 percent had reported no difficulty driving at night before surgery, compared with more than 60 percent at one year and two years after surgery. In comparison, among contact lens wearers who reported no difficulty with night driving, the rate remained around 40 percent at one and two years.

    Around 30 percent of contact lens wearers reported not experiencing dry eye during the past week at baseline and at two years; at the same time points, around 45 percent of former contact lens wearers who underwent LASIK reported not experiencing dry eye during the past week. Forty-five percent of former spectacle wearers who were treated with LASIK reported dry eye during the previous week at baseline compared with 38 percent two years after LASIK. Many of these patients had been contact lens intolerant because of dry eye.—Lori Roniger

    Dr. Price is a consultant for Allergan, Lenstec, and Ophtech; has an equity ownership interest in Calhoun Vision, ReVital Vision, and TearLab; receives lecture fees from Oculus and Staar Surgical; and receives lecture fees and grant support from Bausch + Lomb.

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    What’s Your Story?
    The Story Wall is an interactive feature of AAO 2014 that invites you to share your responses to questions both clinical and culinary.

    On Friday, early responses ranged from the thought provoking (“Make friends with your complications!”) to the stomach turning (“Macaroni and cheese,” in response to a query about favorite pizza toppings).

    Join the narrative by adding your answer to the Story Wall, which is located in the Grand Concourse, Level 3, Lobby. You’ll pass it as you go through the main entrance to the Retina Subspecialty Day area in North Hall B.

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    The Quotable Ophthalmologist
    “If you believe that anatomy predicts function, as we do, then you understand the potential,” said Darius M. Moshfeghi, MD, while advocating for universal screening of newborns.

    “Lunch is next. For lunch, you need a rumbling stomach. For a rumbling stomach you need a rumbling roller coaster. To create a rumbling roller coaster, we selected the best surgeons on this planet to share with you their most exciting videos,” said Amar Agarwal, MD, during his introduction to the Video Lens Complications session during Refractive Surgery Subspecialty Day.

    “Right now, astronauts take several pairs of glasses into space, as they know their refraction will change,” said Dorit B. Donoviel, PhD, during Thursday’s OIS@AAO.

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    Guest Medical Editor:
    Michael Singer, MD

    Managing Editor:
    Chris McDonagh

    Patty Ames, Peggy Denny, and Susanne Medeiros

    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.

    If you would like to update your email address or be removed from the mailing list, send a request toeyenet@aao.org. Questions? Comments? Email Chris McDonagh at cmcdonagh@aao.org.

    ©2014 American Academy of Ophthalmology. All rights reserved.

    EyeNet provides you with all of the information you need to make the most of the Annual Meeting. Be sure to check out EyeNet’s meeting publications:

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    Learn About the Ebola Virus
    Learn About the Ebola Virus
    Gordon M. Trenholme, MD, will get you up to speed on Sunday (12:45-1:45 p.m.) in Room E450.
    V I E W

    Dr. Steven Schwartz shares just-published evidence showing that treatment with transplanted stem cells is safe and beneficial in patients with macular atrophyDr. Steven Schwartz shares just-published evidence showing that treatment with transplanted stem cells is safe and beneficial in patients with macular atrophy

    Dr. George Waring discusses the current landscape of presbyopia correctionDr. George Waring discusses the current landscape of presbyopia correction
    Sen. Rand Paul (R-Ky.) at AAO 2014.
    Sen. Rand Paul (R-Ky.) at AAO 2014. Read EyeNet’s profile of the senator and hear him speak during Monday’s ACA symposium (8:00-10:30 a.m.) in Room S406a.
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    Saturday, October 18

    Highlights from the Friday and Saturday Subspecialty Day meetings.

    Laser Surgery Still Not on Par With Conventional Phaco
    While it undoubtedly provides cleaner incisions and capsulotomies, femtosecond laser surgery still needs to evolve more to reach the cost-effectiveness of phaco, a three-member jury of ophthalmologists decided at the Refractive Surgery Subspecialty Day meeting on Friday.

    They reached their conclusions after hearing three pairs of protagonists debate laser-assisted lens surgery versus conventional phaco on three counts.

    Efficiency. The jury voted 2-1 in favor of conventional phaco being more efficient in terms of the time it takes to perform cataract surgery.

    Visual outcomes. The jury again voted 2-1 that there is no convincing evidence that laser surgery provides better visual outcomes than conventional phaco.

    Safety. On safety, however, it was a hung jury, with one panelist voting in favor of laser surgery, one in favor of conventional phaco, and one abstaining. 

    “I think originally when the femtosecond laser came out, the thought was that this would make mediocre surgeons good and good surgeons great,” said panelist Richard S. Hoffman, MD, but it seemed to him that “femtosecond surgery has made mediocre surgeons dangerous and has made good surgeons slow,” though he added that this opinion was a generalization and that he might have a bias because he has seen a lot of the resulting complications. “Unfortunately, we’re comparing people still on their learning curve to experienced phaco surgeons, but that’s where we’re at right now. It’s hard to say five years from now what an experienced phaco surgeon will be like compared to an experienced femtosecond laser surgeon, but currently I believe that conventional phaco is safer.”

    But most of the literature on femtosecond laser safety involves the original machines, responded jury member Sheraz M. Daya, MD. “There was a rush to publish, and we were talking about, in a sense, prototype machines; in some ways they were medieval compared to what we have today, two years later. So I don’t really think comparing what’s out there in the published literature is really reflective of what’s taking place right now. For me, I don’t find [laser surgery] in any way unsafe. In fact, I’d have to say that it’s safer.”—Mark Simborg

    Dr. Daya is a consultant for Carl Zeiss Meditec, SARcode Bioscience, Staar Surgical, and Tear Science; is a consultant and receives lecture fees from Bausch + Lomb and Nidek; has an equity ownership interest in PRN; and receives grant support from Abbott Medical Optics. Dr. Hoffman is a consultant for Carl Zeiss Meditec and Microsurgical Technology.

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    Cross-Linking Research Moves Ahead in the United States
    Although corneal collagen cross-linking (CXL) is not yet approved by the U.S. Food and Drug Administration (FDA), multiple CXL clinical trials are being conducted on the procedure in the United States, said Peter S. Hersh, MD, during the Refractive Surgery Subspecialty Day meeting on Friday. He is hopeful for “good news” that CXL, which is already an accepted treatment modality worldwide for reducing progression of keratoconus and ectasia, will be FDA approved by the end of March.

    Numerous CXL procedures are being performed in this country as part of clinical trials involving more than 100 practices, and around 10 independent physician studies are also under way, he said. Use of CXL as an adjunct to LASIK to strengthen the cornea and improve refractive stability continues to be investigated. Other CXL studies in the United States are examining riboflavin formulations, delivery techniques, combined procedures (with Intacs, conductive keratoplasty, microwave, phototherapeutic keratectomy, and photorefractive keratectomy), as well as its use in infectious keratitis.

    Meanwhile, an Avedro-sponsored U.S. clinical study on LASIK and CXL for high myopia is planned to begin in early 2015. International studies sponsored by Avedro are under way for refractive CXL.—Lori Roniger

    Dr. Hersh is a consultant for Avedro and receives grant support from Addition Technology and SynergEyes.

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    Approaching Amblyopia as a Binocular Disorder
    The predominant theory of amblyopia has long been that, due to interocular suppression, the immature visual cortex fails to develop adequate connections to the suppressed eye, resulting in a structurally monocular system, explained Eileen E. Birch, PhD, during the Pediatrics Subspecialty Day meeting. However, some amblyopia researchers are concluding that it is a functional, rather than structural problem, in which imbalanced suppression renders a structurally intact binocular visual system functionally monocular. This new approach is the basis for novel therapies.

    In a related presentation, Robert F. Hess, PhD, noted that it is becoming clear that function in amblyopic adults is not lost but suppressed, leaving open the possibility of vision recovery using a variety of approaches. He summarized research demonstrating a direct relationship between the degree of suppression and degree of amblyopia, and greater binocular function with less suppression.

    Drs. Birch and Hess both discussed new treatment of amblyopia based on these new theories and research in which pediatric or adult patients play dichoptic video games on iPads and iPods for an hour a day while wearing anaglyphic red-green glasses. The results are demonstrating improvements in visual acuity and decreases in the severity of suppression.—Lori Roniger

    Dr. Birch receives grant support from Fight for Sight, NEI, and Thrasher Research Fund. Dr. Hess has a patents/royalty interest in Amblyotech.

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    Medical Treatment for Amblyopia
    According to results from the Pediatric Eye Disease Investigator Group, levodopa can produce a subtle, slow improvement over time in older children with residual amblyopia, said Michael X. Repka, MD, MBA, during the Pediatric Ophthalmology Subspecialty Day meeting.

    Study protocol.
    Levodopa—which is not FDA approved for the treatment of amblyopia—was evaluated by the Pediatric Eye Disease Investigator Group in a study of children between the ages of 7 and 12 who had residual amblyopia. “This was not evaluated as initial therapy,” Dr. Repka cautioned. Patients were randomized to receive either placebo or 0.76 mg of oral levodopa plus 0.17 mg of carbidopa; both groups also underwent two hours of patching daily. The treatment period was 16 weeks, and follow-up was conducted for an additional 10 weeks. (Concomitant administration of carbidopa allows researchers to reduce the dose of levodopa by about 75 percent, thus lowering the risk of side effects.)

    Visual acuity results. Patients in the levodopa group improved by an average of 5.2 letters, while those in the placebo group improved by 3.8 letters. Subanalysis showed that 15 percent of the levodopa group improved by 10 letters or more, compared with 4 percent of the placebo group.

    Side effects. In the levodopa group, 20 percent experienced headache, compared with 8 percent of the placebo group. Nausea was an issue for 7 percent of the levodopa patients versus 12 percent of those in the placebo cohort.—Jean Shaw

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    Coordinating With a Multispecialty Team
    Working with other specialists to manage the uveitis patient presents a particular challenge, said Erik Letko, MD, at the Uveitis Subspecialty Day meeting. “There is no published literature on this topic,” perhaps because uveitis is a relatively uncommon condition.

    Given that background, Dr. Letko offered a few pointers from his own experience on working with other specialists.

    Consider your practice.
    Factors that need to be taken into account include your training, your experience with systemic therapies, whether you have access to subspecialists, and your geographic area. Even the question of whether your office is up to speed on electronic health records (EHRs) needs to be considered, as EHRs can facilitate the coordination of care.

    Beware of false comforts.
    Nailing down the diagnosis and starting the patient on treatment can offer false comfort, he said, as can initial response to treatment with corticosteroids. Ironically, referring patients can be another source of false comfort. “We [uveitis specialists] are the primary caretakers of these patients.”

    Remember the big picture.
    The odds are that a systemic condition is involved, so don’t get bogged down in small details. Recognize the need for referral when it’s warranted, and communicate “early and often” with all other members of the team.—Jean Shaw

    Dr. Letko reports no related financial interests.

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    Recent Advances in Lab Tests for Uveitis
    When it comes to diagnosing uveitis, traditional laboratory tests are being supplanted by newer options, said Russell N. Van Gelder, MD, PhD, during the Uveitis Subspecialty Day meeting. For instance, when a clinician wants to rule out syphilis, the FTA-Abs and MHA-TP tests are being replaced by the syphilis IgG test, he said. “Syphilis IgG should be a first-line screening test.”

    Some points to consider with regard to common underlying systemic conditions:
    • Syphilis. If the IgG test is positive, you will want to confirm those results with the rapid plasma reagin (RPR) test and, in challenging cases, polymerase chain reaction (PCR).
    • Tuberculosis. The interferon-gamma release assays (e.g., QuantiFeron-TB Gold and TB-Spot) are supplanting tuberculin skin testing.
    • Sarcoidosis. The angiotensin-converting enzyme and lysozyme tests are of limited utility, and a chest x-ray is recommended for screening. As “the tissue is the issue” in sarcoidosis, Dr. Gelder said, it’s worth noting that recent evidence suggests that vitrectomy may be helpful in making the diagnosis.
    On the horizon: new iterations of PCR, notably pan-bacterial and pan-fungal tests. And the next frontier will be deep DNA sequencing. But no matter the test, one basic strategy remains essential: “Test selection must be based on history and presentation.”—Jean Shaw

    Dr. Van Gelder receives grant support from the NEI, Novartis Pharmaceuticals, and Theravance.

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    Not in Chicago? Watch AAO 2014 Online
    The Academy will be streaming some events live and also will be posting interviews about this year’s sessions online.

    Watch live streaming of AAO 2014 events. For a front-row seat, sign up for the Virtual Meeting. On Sunday, for instance, four events will be streamed:
    • The Opening Session (8:30-10:00 a.m., CST)
    • Spotlight on Pediatric Ophthalmology: Front Line and First Steps—Management of Strabismus for the Comprehensive Ophthalmologist (10:30 a.m.-noon)
    • Treatment for Wet and Dry AMD: Where We Are and Where We Are Going (10:30 a.m.-noon)
    • Grand Rounds: Cases and Experts From Across the Nation (2:00-3:15 p.m.)
    Watch interviews with AAO 2014 presenters. Starting on Sunday, visit AAO TV, where a range of topics will be discussed. The first day of interviews will provide perspectives from Academy President Gregory L. Skuta, MD, and Academy CEO David W. Parke II, MD, plus discussions of the IRIS Registry, the use of Google Glass in ophthalmology, ICD-10, and more.

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    The Quotable Ophthalmologist
    Henry D. Jampel, MD, in his American Glaucoma Society Lecture, The Quarter Century’s Progress in the Treatment of Open-Angle Glaucoma: “The least invasive glaucoma operation today is phacoemulsification.”

    Vincent de Luise, MD, describing a particularly confounding case in his Cornea Subspecialty Day presentation, Episcleritis and Scleritis—The Good, the Bad, the Ugly: “So what would you do with this patient—call a specialist? Oh, wait, we are the specialists.”

    Presenter at Glaucoma Subspecialty Day, narrating his video of a surgical complication: “Now, the key thing is to avoid doing that … which I just did.”

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    Erratum—2015 Medicare Update Event
    Sunday’s 2015 Medicare Update event takes place 12:15-1:45 p.m in Grand Ballroom S100c. (The ending time published in Washington Report Express was incorrect.)

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    Guest Medical Editor:
    Steven J. Gedde, MD

    Managing Editor:
    Chris McDonagh

    Patty Ames, Peggy Denny, and Susanne Medeiros

    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 AAO 2014 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.

    If you would like to update your email address or be removed from the mailing list, send a request toeyenet@aao.org. Questions? Comments? Email Chris McDonagh at cmcdonagh@aao.org.

    ©2014 American Academy of Ophthalmology. All rights reserved.

    EyeNet provides you with all of the information you need to make the most of the Annual Meeting. Be sure to check out EyeNet’s meeting publications:

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    Sen. Rand Paul (R-Ky.) at AAO 2014.
    Sen. Rand Paul (R-Ky.) at AAO 2014. Read EyeNet’s profile of the senator and hear him speak during Monday’s ACA symposium (8:00-10:30 a.m.) in Room S406a.
    V I E W

    Dr. William Wiley describes early outcomes from the light-adjustable lens trials in the United StatesDr. William Wiley describes early outcomes from the light-adjustable lens trials in the United States

    Dr. Thomas Lietman describes surprising results from his recent study  comparing topical natamycin and voriconazole for filamentous fungal keratitisDr. Thomas Lietman describes surprising results from his recent study  comparing topical natamycin and voriconazole for filamentous fungal keratitis

    Good morning happy Sunday! I am so happy to be in Chicago! I am doing what I love ophthalmology! #Chicago #aao2014 #JCAHPO @aao_ophth

    An ophthalmologist should be three things: A good clinician, a good scientist, and a good teacher. - Dr. Vollmann #aaoyo @aao_ophth #aao2014
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    Sunday, October 19



    The Ebola Virus

    With fear and misinformation about Ebola spreading as fast as the virus, the Academy invited Gordon M. Trenholme, MD, an infectious disease specialist at Rush University Medical Center, to give a talk at AAO 2014.

    Dr. Trenholme and his team at Rush have been working around the clock to prepare for any scenario, as the CDC may soon designate their center for any possible Ebola cases in the Chicago area.

    Dr. Trenholme stressed that this is not an airborne disease, and it cannot be contracted through water or food. It is transmitted principally by direct physical contact with an ill person or their body fluids during the later stages of illness.

    In a survey by Doctors Without Borders that included 27 confirmed patients who had a total of 173 household contacts—meaning people who lived in the same hut—the transmission rate was only 16 percent. Only those who were caring for their infected family members at the end of their life contracted the disease. “Think about the flu virus,” Dr. Trenholme said, suggesting that it’s far easier to contract flu than Ebola.

    Although Ebola is virulent, it’s not a particularly hearty virus. Bleach kills it. Dr. Trenholme also shared his hospital’s infection control protocol, which includes a detailed protocol for personal protection equipment (PPE). They have a 23-step procedure just for donning the PPE, which is done under direct supervision by two assistants. It’s a process he says takes him one-and-a-half hours.

    He says he’s frequently asked to speculate about how two nurses from the United States became infected, and he believes it’s most likely that their PPE was inadequate.

    Dr. Trenholme said an ophthalmologist today asked him, how do we stop this? The answer is getting more patients in Africa into treatment centers. It’s the family members who care for these patients at the end of their life and then prepare their bodies for burial who are most at risk. If most of these patients were in a treatment center instead of at home, they could begin to control Ebola’s spread.

    “I don’t know why Congress is waiting to approve money for treatment centers,” Dr. Trenholme said.—Susanne Medeiros

    See tomorrow’s Academy Live for more information on Ebola’s clinical manifestations.

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    Retinoblastoma: 50 Years of Progress
    Fifty years ago this month, Edwin B. Dunphy, MD, divided the history of retinoblastoma into four stages—prehistologic, histologic, enucleation, and irradiation and chemotherapy.1

    In this year’s Jackson Memorial Lecture, Hans E. Grossniklaus, MD, added three categories to account for the rapid pace of scientific discovery and medical management in the intervening decades—molecular biology, targeted treatment, and global health awareness.

    “It’s time to update the retinoblastoma story,” said Dr. Grossniklaus, who provided an overview of such topics as the cytologic features of the disease, genetic sequencing, clinical staging, chemoreduction, and intra-arterial therapy. “The most far-reaching advances have come in the understanding of genetics and molecular origins and progression of the tumor,” said Dr. Grossniklaus, citing a recent study on gene expression and disease subtypes.2

    But it’s Dr. Grossniklaus’ last category—global health awareness—that presents the greatest challenge, given social barriers that block access to care.3 Each year, the United States, Japan, and Nigeria will each see 200 to 300 newly diagnosed cases, with another 1,000 new cases each in China and India. While the overall survival rates exceed 90 percent in the developed countries (ranging from 93 percent in Europe to 97 percent in the United States), they are as low as 40 percent in low-income developing countries.

    Overall, the retinoblastoma story is one of remarkable success, Dr. Grossniklaus concluded. “In this one disease, we have come to understand the basic mechanisms of cancer.” However, he cautioned, “The current challenge is not technological, but social.”—Jean Shaw

    1 Dunphy EB. Am J Ophthalmol. 1964;58(4):539-552.
    2 Kapatai G et al. Br J Cancer. 2013;109(2):512-525.
    3 Wilson MW et al. Pediatrics. 2006;118(2):e331-336.

    Dr. Grossniklaus receives grant support from Alcon Laboratories, Aura Biosciences, Fight for Sight, and the National Cancer Institute, and has a patents/royalty interest in Clearside Biomedical.

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    Expert Panel Dissects Wet and Dry AMD
    Copious data from large randomized trials such as MARINA, ANCHOR, and AREDS point to the benefits of anti-VEGF agents and nutritional supplements in managing wet and dry AMD; still, the best treatment remains prevention in the form of exercise and a healthy diet. That was the general consensus of a panel in a symposium on current and future treatment modalities for AMD. “As far as diets rich in fish and fruits and vegetables—the more you eat, the less chance you will have of getting AMD,” said panelist Emily Y. Chew, MD.

    The panel also discussed the gray areas of AMD management, such as which drug combinations may work best and what new risk factors are emerging as potential precursors of early AMD. “There are certain types of lesions associated with AMD, and our understanding of those lesions is starting to change,” said R. Theodore Smith, MD. He noted the relatively recently discovered phenomenon of subretinal drusenoid deposits, which, like soft drusen, have proved to be part of the pathway to geographic atrophy and choroidal neovascularization.

    As to the future of AMD treatment, combination therapies may synergistically target different pathways, increasing the durability of current therapies, decreasing the frequency of injections, and potentially increasing safety. The latest advancements, though, involve gene therapy and drugs currently being tested such as pazopanib and lampalizumab.—Mark Simborg

    Dr. Chew reports no related financial interests. Dr. Smith is a consultant for Advanced Cell Technology.

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    Can We Better Prepare the Residents of 2015 for the Practice of 2020?
    In a wide-ranging panel conversation led by Thomas A. Oetting, MD, four residency experts discussed the shifting sands of residency education and forthcoming challenges. Here’s a brief synopsis.

    Paradigm shifts. New models of learning and working are becoming increasingly important. Newly trained ophthalmologists “will need to work in teams, have self-improvement skills, and be responsible for self-directed learning throughout their careers,” said Tara A. Uhler, MD.

    Anthony C. Arnold, MD, concurred. “Working in interdisciplinary teams, practice-based learning, systems-based treatment—these are becoming more and more important.” 

    The internship year. Ophthalmology residents undergo 48 months of postgraduate training. But, as Dr. Oetting pointed out, “One-fourth of their training is out of our control with the internship year.” Dr. Arnold responded, “This is a really controversial issue. Do you cut short the general medicine part of that year? There are significant downsides to that.” 

    Fellowship training. At present, more than 50 percent of ophthalmology residents go on to fellowships, noted Paul Sternberg Jr., MD. This “somehow suggests that basic training wasn’t enough. Do we incorporate more subspecialty training into the residency?”

    There are three reasons why residents go into fellowship training: 1) To find their niche, 2) because they don’t feel ready to practice independently, or 3) because they’re planning to go into a subspecialty, said Dr. Arnold. “Number two is something we can attack.”

    Editing the curriculum. “I worry that now that residents work with an autorefractor, they’re not as good at refracting; and now that they work with optical coherence tomography, they’re not as good at looking at the macula,” said Dr. Sternberg. “So how can they get those skills when we’re piling on so many other competencies in a short period of time?”

    Ophthalmology programs “have a perfect storm/perfect opportunity,” said Nicholas J. Volpe, MD. “Residents need to be trained how to access information, how to know when things are serious—how do we give this information to residents in the context of a new health care system?” He suggested that one solution may be to move to a case-based system that would incorporate electronic methods of accessing information.—Jean Shaw

    Drs. Arnold, Oetting, Sternberg, Uhler, and Volpe report no related financial disclosures.

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    Best Papers
    During this year’s Original Papers sessions, the expert panels moderating those presentations each named the paper they rated most highly. Today’s best papers are as follows.
    • Cataract (Part 1). Impact of First Eye vs. Second Eye Cataract Surgery on Quality of Life, presented by Nakul Shekhawat, MD
    • Cataract (Part 2). Influence of Ophthalmic Viscosurgical Device on Intraoperative Aberrometry, presented by Samuel Masket, MD
    • Cornea. Bowman Layer Implantation to Reduce and Stabilize Advanced Progressive Keratoconus, presented by John Steven Parker, MD
    • Uveitis. Self-Reported Experience With Side Effects From Medications Used to Treat Noninfectious Nonanterior Uveitis, presented by Nisha Acharya, MD
    Ten more Original Papers sessions will take place on Monday and Tuesday.

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    Off to a Running Start
    During this morning’s Run for Vision, 312 meeting attendees raised more than a sweat—they also raised more than $16,000 for the Eye Bank Association of America. This year’s winner, Nicolai Sjoe, finished the 5-km course in 18:09 minutes. The fastest woman was F. Allison Watts, who completed the course in 21:31 minutes.

    The runners ranged in age from 18 to 75. The 29th annual Run for Vision was once again sponsored by Bausch + Lomb.

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    The Quotable Ophthalmologist
    “Fiat lux—let there be light—this is the core mission of ophthalmology,” said Stefan Seregard, MD, President of the European Society of Ophthalmology, during the Opening Session.

    “If we aren’t there, someone else will be there. As the saying goes, ‘If you’re not at the table, you’re probably on the menu,’” said Tara A. Uhler, MD, discussing the need to foster a commitment to advocacy among ophthalmology residents.



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    Smartphones for Monitoring Dry AMD
    Now that nearly 60 percent of the U.S. population uses a smartphone, the race is on to develop ophthalmic-related applications. One area of development is directed at dry age-related macular degeneration (AMD), with more than a half-dozen apps offered to patients for at-home monitoring of visual acuity (VA).

    During her presentation at Retina Subspecialty Day on Saturday, Anne Fung, MD, focused on two apps that have what she termed “the most robust cloud support for patient data.”

    SightBook (DigiSight).
    This app is a smartphone-based visual acuity (VA) testing algorithm. A test menu is presented, and the patient can choose from basic or advanced VA tests. The app has been evaluated in three clinical trials; the most recent study found that the app has high test-retest reliability and good agreement with ETDRS distance VA and standard near vision testing.

    myVisionTrack (Visual Art and Science).
    This prescription-only, FDA-approved app is based on a shape discrimination algorithm. Four circles are presented, and the patient must touch the one with distortion. The 10-minute test can be done twice weekly or at the physician’s discretion. This app has been tested in two clinical trials, one of which demonstrated a high rate of patient compliance, with 84 percent of patients consistently testing their vision one or more times a week.—Jean Shaw

    Dr. Fung has an equity ownership interest in DigiSight.

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    Cannabis for Glaucoma Is a Lot of Smoke
    Marc F. Lieberman, MD, discussed the use of medical cannabis for glaucoma on Saturday, and he told ophthalmologists that although it has modest IOP-lowering effects, “it is less effective than currently available topical glaucoma therapies.”

    He added that it is the consensus of the Academy, National Eye Institute, American Glaucoma Society, and Canadian Ophthalmological Society that marijuana should not be used for glaucoma management. Nevertheless, he said, the proponents of marijuana legalization have been misrepresenting its effectiveness for treating glaucoma.

    He noted that researchers have been unable to quantify the agents and mechanisms in cannabis that are responsible for lowering IOP. With more than 480 active chemicals, it is difficult to study, he said.

    But he said that we should still be keeping it “in our sights for other medical uses,” such as chemotherapy-induced nausea, AIDS-related wasting syndrome, and chronic neuropathic pain. However, he cautioned that chronic marijuana use is not benign. Placing the history of marijuana’s legal status into a sociopolitical context, Dr. Lieberman said that its classification as a Schedule I controlled substance with no acceptable medical use was politicized and had racist and xenophobic origins.

    He said that some patients do believe that marijuana is helpful for glaucoma, and he is asked to write prescriptions for it. “We doctors are caught in the middle,” he said.

    He advised ophthalmologists to do as he does: “I educate patients, refrain from prescribing, and try to do no harm.”—Lori Roniger

    Dr. Lieberman reports no related financial interests.

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    Using Immunomodulatory Therapy to Treat Uveitis
    Ophthalmologists have much to learn from their rheumatology colleagues when it comes to uveitis therapy, said C. Stephen Foster, MD. The paradigm in rheumatology has shifted from cautious use of steroids and nonsteroidal anti-inflammatory drugs (NSAIDs) to early employment of steroid-sparing, immunomodulatory disease-modifying agents—with the result of vastly superior outcomes and a lower risk of toxic side effects, he said, during the Uveitis Subspecialty Day meeting.

    “Ophthalmologists should embrace this model” with even more vigor, said Dr. Foster, “since the eye is so much less forgiving of chronic inflammation than is the joint, with profound life-altering consequences.”

    When IMT is mandatory.
    Although steroids still have a place in uveitis treatment—there is “nothing like them” when it comes to putting out the fire of acute inflammation, Dr. Foster said—immunomodulatory therapy (IMT) is mandatory in certain situations. These include 1) potentially life-threatening diseases, such as Behçet with retinal vasculitis, polyarteritis nodosa, or rheumatoid arthritis with necrotizing scleritis or peripheral ulcerative keratitis; and 2) blinding ocular disease that does not respond well over the long term to steroid therapy, such as multifocal choroiditis and panuveitis, birdshot retinochoroidopathy, and serpiginous choroiditis.

    When IMT may be considered. Dr. Foster recommends IMT for chronic or recurrent juvenile idiopathic arthritis (JIA), sarcoid disease, pars planitis, and idiopathic uveitis. “With JIA, I’d say sooner rather than later,” he said. Other diseases in this category are tubulointerstitial nephritis and HLA-B27–associated disease.

    Rules of referral. If you’re using IMT, refer to or partner with a rheumatologist or hematologist, he said.—Jean Shaw

    Dr. Foster receives grant support from Alcon Laboratories, Novartis Pharmaceuticals, and Santen; is a consultant to and receives grant support from Abbott Medical Optics and Bausch + Lomb; has an equity ownership interest in and receives grant support from Eyegate Pharmaceuticals; is a consultant to and receives lecture fees from IOP Ophthalmics and XOMA; and is a consultant to and receives lecture fees and grant support from Allergan and Lux Biosciences.

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    Treating Glaucoma in the Presence of Other Eye Diseases
    Panelists at Glaucoma Subspecialty Day discussed when and how to diagnose or treat glaucoma, or possible glaucoma, in the presence of other eye diseases.

    Scenario 1. The first case involved a 46-year-old myopic Chinese woman with normal-tension glaucoma and a history of mitral valve prolapse, hypotension, and sleep apnea. She had significant visual field loss, with intraocular pressure (IOP) in the mid to high teens on maximal medication, but she was refusing surgery. “Now this was a lady who’s an engineer in Silicon Valley, so she’s too smart to have a trabeculectomy,” commented case presenter Shan C. Lin, MD. “So what would you do?” The panel concurred that the patient should begin the process of seriously considering tube shunt surgery, with a potential alternative therapy of treating the sleep apnea.

    Scenario 2. Jeffrey M. Liebmann, MD, then presented two cases of glaucoma occurring with paracentral visual field loss and asked the panel: Should 10-2 central visual field testing be a routine part of glaucoma management? The panel was divided on this issue, with some doing 10-2 tests only rarely and others giving them at least once to all patients. However, all panelists agreed that it depends on the patient, and treatment considerations should take into account other tests, including the 24-2 test, and imaging.

    Scenario 3. In the next case, presented by Richard P. Mills, MD, MPH, a 56-year-old male physician was visually asymptomatic when bilateral optic disc drusen were discovered on a routine eye examination. He had typical disc appearance with visible drusen and optic nerve pallor, which obscured the central cup. His initial IOP was 15 mmHg in the right eye and 16 mmHg in the left eye, and he had a small arcuate field defect. Dr. Mills asked the panel if they would treat the patient with IOP-lowering therapy at this point. The panel concurred that there is insufficient evidence to recommend IOP-lowering therapy, as it could not be determined whether the field defect was the result of the drusen or glaucoma. However, the patient should be informed of the possibility of treatment and its benefits and risks.

    Scenario 4. The last case involved a 62-year-old Caucasian woman with a long history of type 2 diabetes. She also had a history of neovascular glaucoma secondary to proliferative diabetic retinopathy with fluctuating IOP (14-25 mmHg) since undergoing Ahmed tube shunt surgery in 2010 and progression of visual field and OCT defects. Further ocular history included diabetic macular edema, anti-VEGF injections, and multiple sessions of panretinal photocoagulation. Case presenter Young H. Kwon, MD, PhD, asked the panel if the visual field progression was due to her glaucoma or her diabetic retinopathy—and how they would proceed with the treatment. The panel concurred that because of apparent progression, the patient should give serious consideration to further IOP-lowering treatment, possibly surgery.—Mark Simborg

    Dr. Kwon has an equity ownership interest in Free Educational Publications. Dr. Lin is a consultant for Allergan. Dr. Liebmann is a consultant, has an equity ownership interest, and/or receives grant support from Alcon Laboratories, Allergan, Bausch + Lomb, Carl Zeiss Meditec, Diopsys, Heidelberg Engineering, Merz Pharmaceuticals, NEI, New York Glaucoma Research Institute, Optovue, Quark Pharmaceuticals, Reichert, SOLX, Sustained Nano Systems, Topcon Medical Systems, and Valeant Pharmaceuticals. Dr. Mills is a consultant for Allergan.


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    Guest Medical Editor:
    Steven I. Rosenfeld, MD

    Managing Editor:
    Chris McDonagh

    Patty Ames, Peggy Denny, and Susanne Medeiros

    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 AAO 2014 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.

    If you would like to update your email address or be removed from the mailing list, send a request toeyenet@aao.org. Questions? Comments? Email Chris McDonagh at cmcdonagh@aao.org.

    ©2014 American Academy of Ophthalmology. All rights reserved.

    EyeNet provides you with all of the information you need to make the most of the Annual Meeting. Be sure to check out EyeNet’s meeting publications:

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    V I E W

    Dr. SriniVas Sadda discusses whether anti-VEGF therapy for wet AMD induces geographic atrophyDr. SriniVas Sadda discusses whether anti-VEGF therapy for wet AMD induces geographic atrophy

    Dr. Usha Chakravarthy talks about the long-term systemic safety profile of anti-VEGF therapyDr. Usha Chakravarthy talks about the long-term systemic safety profile of anti-VEGF therapy

    Highlight from yesterday: Elisabeth Cohen's lecture on #zoster; terrible disease, needs aggressive prevention & treatment #aao2014 #cornea

    Great week at #aao2014! Terrific lectures in a great city! pic.twitter.com/KTLxJSOmsT
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    Monday, October 20

    NEWS FROM AAO 2014

    NEWS FROM AAO 2014

    Sen. Rand Paul Discusses Health Care
    The marketplace, not the government, should determine the price of health care to allow for the most efficient and affordable distribution of services, said Sen. Rand Paul (R-Ky.), when he delivered this morning’s Parker Heath Lecture.

    “The correct price of a good is the price at which the most stuff is distributed to the most people,” said Sen. Paul. “Only the marketplace can figure that out.”

    In his half-hour talk, Sen. Paul said it should be a collective of individuals in a free market economy—as opposed to bureaucratic or political entities—that should determine the cost of health care services, and he did not shy away from taking jabs at Washington for its decision-making gridlock.

    “It’s great to be with normal people for a change,” Sen. Paul remarked when he took the podium. “I think physicians tend to be problem solvers. We tend to analyze a problem and apply a remedy based on facts, not preconceptions.”

    Apart from letting the marketplace set health care prices, Sen. Paul advocated for folding Medicare into the federal employee health plan, repealing the Obama administration’s medical devices tax, expanding the use of health savings accounts, and reserving government subsidization and insurance for people with chronic illness or who in some other way represent the exception to the rule that the insurance system was originally built to address. “As physicians we think of health care as a medical problem,” he said. “Only when we begin to understand that the most vexing medical problems are really economic problems will we be closer to a cure.”

    Sen. Paul ended by calling on members of the audience to take action. “I think it would be an improvement if politicians acted more like doctors and if doctors became more involved in politics,” he said. “The fact is everyone in this room can help. The voices in this room belong to experts in ophthalmology and leaders in your communities across the United States. You should stand up and be heard.”—Mark Simborg

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    Cataract Spotlight
    Difficult cases, potential disasters, near misses, and clinical pearls: Here are just a few highlights from the 13th annual Cataract Spotlight session.

    Preventing the Argentinian flag sign. Brock K. Bakewell, MD, recommended the following steps: 1) Apply trypan blue under an ophthalmic viscoelastic device (OVD), 2) minimize posterior pressure, 3) use dispersive OVD and decompress the anterior chamber, 4) create a 3-mm capsulorrhexis in case the posterior cortical space still has positive pressure, and 5) consider using the femtosecond laser.

    Is 10-0 Prolene biodegradable? Some disagreement emerged on this point, with Walter Stark, MD, stating that it isn’t, even eight to 10 years out. “Do not put it through the hole in the haptic or optic, if you’re going to use it.” But Nick Mamalis, MD, said, “I have to respectfully disagree … we’ve seen degradation over time.” And this occurred in cases in which intraocular lenses (IOLs) with smooth haptics—not square-edged IOLs—had been sutured to the iris or sulcus, Dr. Mamalis said.

    Dealing with a misaligned toric IOL. Warren Hill, MD, suggested that cataract surgeons take a hint from aviation when faced with conflicting information on a toric IOL: “You want a primary instrument and two supporting instruments.” Specifically, using the topographic axial power map, first determine the orientation of both the steep and flat meridians, and then measure the power difference between orientations. And David F. Chang, MD, whose case was being discussed, remarked that it is better not to have a toric IOL than one that is malpositioned.

    What to do when faced with a loose lens. First step? “Save a life!” said Michael Snyder, MD. As the list of contributing causes of a loose lens includes Marfan syndrome and homocystinuria, it’s essential that these patients be screened by an internal medicine specialist, he said. Also on his list of top 10 tips for these cases: “It’s a good idea to borrow a retina specialist from time to time.”—Jean Shaw

    Dr. Bakewell is a consultant for Abbott Medical Optics. Dr. Chang has an equity owner interest in Calhoun Vision, ICON bioscience, LensAR, Minosys, PowerVision, Revital Vision, and Versant Ventures; is a consultant to Abbott Medical Optics; is a consultant and has an equity ownership interest in Clarity and Transcend Medical; receives lecture fees from Allergan; and has a patents/royalty interest in Slack. Dr. Hill is a consultant for Oculus and Powervision; is a consultant and receives lecture fees from Alcon; is a consultant and has an equity ownership interest in Clarity; and is a consultant and receives grant support from Haag-Streit. Dr. Mamalis receives grant support from ARC Laser Corporation, Aaren Scientific, Alcon Laboratories, Allergan, Bausch + Lomb, Calhoun Vision, Nu-Vue Technologies; and is a consultant and receives grant support from Abbott Medical Optics, Anew Optics, and Medennium. Dr. Snyder is a consultant for Alcon Laboratories, Haag Streit, and Humanoptics. Dr. Stark has an equity ownership interest in VueCare Media.

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    Reimbursement Affects Wet AMD Treatment Patterns on Both Sides of the Pond
    Ophthalmologists from opposite sides of the Atlantic presented the European and North American approaches to treating various retinal conditions in a “View Across the Pond” joint session with the European Society of Ophthalmology (SOE) on Monday.

    Presentations juxtaposing anti-VEGF treatment of wet AMD in the United States and Europe highlighted the way in which differences in reimbursement can affect treatment patterns and regimens.

    In North America. Representing the North American side of the pond, Jeffrey S. Heier, MD, said that although studies have found bevacizumab (Avastin), ranibizumab (Lucentis), and aflibercept (Eylea) similar in terms of safety and efficacy, bevacizumab accounts for the majority of anti-VEGF injections for wet AMD in the United States. He noted that some insurance companies have threatened physicians with termination if they do not use the least expensive anti-VEGF agent, bevacizumab, and this definitely affects prescribing patterns, even though some physicians believe aflibercept may be better for some patients.

    In Europe. Stephan Michels, MD, MBA, explained some of the challenges of treating wet AMD with anti-VEGF drugs in Europe, noting that approval by the European Medicines Agency doesn’t necessarily mean that there will be reimbursement, as reimbursement is handled on a country-by-country basis. Moreover, reimbursement for a drug is handled separately from reimbursement for injection or imaging. In Germany, with its private health care system, one challenge is that injection and follow-up cannot be billed by the same doctor. And in southern Europe, anti-VEGF treatment for wet AMD is generally available only at hospitals through the public health care systems.

    Close to 80 percent of ophthalmologists in the United States use the “treat and extend” approach to manage wet AMD patients, according to Dr. Heier. According to Dr. Michels, “Unfortunately, in most of Europe, undertreatment is the most common approach,” which is often due to the lack of reimbursement. PRN ends up meaning “treat as much as the system allows you to treat,” he said, adding that he does not believe this is likely to change any time soon due to the current poor economic situation in many countries.—Lori Roniger

    Dr. Heier consults for and/or receives grant support from Acucela, Aerpio Therapeutics, Alcon Laboratories, Alimera, Allegro, Allergan, Bausch + Lomb, Bayer Healthcare, Endo Optiks, Forsight Labs, Fovea Pharmaceuticals, Genentech, Genzyme, Heidelberg Engineering, Kala Pharmaceuticals, Kanghong, Kato Pharmaceuticals, Liquidia, Lpath, Merz, Neurotech, Nicox, Notal Vision, Novartis Pharmaceuticals, Ohr Pharmaceutical, Ophthotech, Oraya, QLT Ophthalmics, Regeneron, Sanofi Fovea, Stealth Peptides, Thrombogenics, and Xcovery. Dr. Michels is a consultant, lecturer, and/or receives grant support from Alimera Sciences, Allergan, Bayer Healthcare Pharmaceuticals, Clanotech, Esbatech, Novartis Pharmaceuticals, and Roche Diagnostics.

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    New Delivery Methods for Posterior Segment Treatment
    A Sunday symposium focused on research being conducted on new methods for delivering treatment to the posterior segment. Here are some of the highlights.

    Encapsulated cell technology. Jeffrey L. Goldberg, MD, PhD, discussed the promising area of optic nerve regeneration in glaucoma by means of intravitreal gene therapy delivered through encapsulated cell technology. He reported that a phase 1 clinical trial on ciliary neurotrophic factor (Neurotech NT-501 implant) has been conducted in 11 primary open-angle glaucoma patients with progressive retinal ganglion cell dysfunction and degeneration. While further analysis is ongoing, preliminary results suggest biological activity with correlated improvements in visual fields and contrast sensitivity.

    Implantable micropump. Mark S. Humayun, MD, PhD, presented on an implantable micropump with a refillable port accessible via a 31-gauge needle through the conjunctiva. The drug reservoir chamber can store up to 100 ?L, and an intraocular cannula releases a microdosage into the vitreous cavity. He discussed a phase 1 clinical trial in which ranibizumab was delivered through an implanted device in 11 diabetic macular edema patients, with no serious adverse events reported during the study’s 90-day duration.

    Thermoresponsive hydrogels. Jennifer L. Kang-Mieler, PhD, discussed research on thermoresponsive hydrogels that could be delivered intravitreally through small-gauge needles. Various agents, such as anti-VEGF drugs, could be encapsulated into the hydrogel and released over time, as well as combined with nano/microspheres. Biocompatibility data has been demonstrated in rodents.—Lori Roniger

    Dr. Goldberg is a consultant for Alcon Laboratories, Allergan, and Theravance; and receives grant support from DOD, GRF, and NIH. Dr. Humayun is a consultant for Clearside and Liquidia; is a consultant and receives lecture fees and grant support from Alcon Laboratories; is a consultant, has a patents/royalty interest in, and receives lecture fees and grant support from Bausch + Lomb Surgical; is a consultant and has a patents/royalty interest in Iridex; is a consultant and has equity ownership and patents/royalty interests in Regenerative Patch Technologies; and is a consultant, has equity ownership and patents/royalty interests, and receives lecture fees and grant support from Reflow, Replenish, and Second Sight. Dr. Kang-Mieler has a patent pending.

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    Two Firsts for Ethics
    This afternoon, ophthalmologists at the Dr. Allan Jensen & Claire Jensen Lecture in Professionalism and Ethics applauded the debut of two ethics resources.

    The inaugural Jensen Lecture—The Regulation of Professional Performance: Whose Responsibility? The five most common hospital-acquired infections cost the United States $9.8 billion annually—and most of those infections are preventable, said Gerald B. Hickson, MD, who is the senior vice president of Quality, Safety, and Risk Prevention at Vanderbilt University Medical Center (VUMC). To improve patient safety, institutions need to create a safety culture, where people are willing to speak up and report lapses in professionalism, said Dr. Hickson.

    Promoting Professionalism Pyramid
    VUMC has a process for reviewing unsolicited patient complaints and has established a coworker observation reporting system. “But we don’t do our duty to patients if we stand back and talk about people rather than talking tothem,” said Dr. Hickson, who described VUMC’s tiered approach to intervention (see “Promoting Professionalism Pyramid”). When an alleged act of unprofessional behavior is reported, the physician is visited by one of his or her peers for an informal “cup-of-coffee” chat about the event, typically within 24 hours. If the physician exhibits a pattern of such behavior, there is a Level 1 “awareness” intervention; if that pattern persists, there is a Level 2 “guidance” intervention.

    Launch of the Redmond Center—an online portal for ethics information and educational resources. Dr. Hickson stressed that organizations need an infrastructure for promoting professionalism, and the new Redmond Center—which offers all the Academy’s ethics resources, and enables ophthalmologists to create ethics educational activities and resolve ethical dilemmas—can provide some of those building blocks. It does so within the existing Academy Policy Statements and Advisory Opinions. The Michael R. Redmond Professionalism and Ethics Center is located on the ONE Network atwww.aao.org/redmondcenter.—Chris McDonagh

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    The Ebola Virus—Screening Procedures and Clinical Manifestations
    In yesterday’s Ebola update, Gordon M. Trenholme, MD, an infectious disease specialist at Rush University Medical Center in Chicago, described his institution’s screening procedures and summarized the condition’s clinical manifestations and course.

    How Rush screens patients. This week, physicians’ offices and outpatient hospital service departments at Rush began screening patients by asking two questions:
    • Have they traveled to an African country where Ebola is present (Guinea, Liberia, or Sierra Leone), or have they had personal contact with someone who has traveled there;
    • and do they have any of the following symptoms: fever, stomach pain, headache, muscle aches, vomiting, internal or external bleeding, and diarrhea?
    These questions can be asked and answered with a patient in one minute or less at a distance of greater than three feet.

    If the patient answers “yes” to both questions, three initial steps will be taken: 1) A staff member will provide the patient with a mask and ask him or her to take a seat or stand away from other patients in the waiting room, 2) a staff member will put on personal protection equipment (PPE) and then escort the patient to a private room, if possible, and 3) a staff member will call security services for an officer, wearing PPE, to escort the patient to the emergency department.

    Clinical manifestations and course. Dr. Trenholme stressed that not all patients present with fever. He noted that 99.5 degrees is a low-grade fever and considered an indication. About 30 percent of Ebola patients have a cough. The differential diagnosis includes malaria, typhoid fever, and meningococcemia.

    The clinical course typically proceeds as follows:
    • Abrupt onset of nonspecific signs and symptoms: fever (>101.5 degrees), chills, myalgias, and malaise.
    • Days 5-7: Diffuse erythematous maculopapular rash involving face, neck, trunk, and arms (if present, may help distinguish Ebola from other infections).
    • Progression to gastrointestinal symptoms: nausea, vomiting, severe watery diarrhea, and abdominal pain.
    • Other symptoms may develop, including chest pain, shortness of breath, headache and confusion, and pharyngitis.
    • Also watch for central nervous system involvement (delirium, somnolence, and photophobia) as well as pancreatitis, jaundice, lymphadenopathy, and conjunctival injection.
    • About 40 percent of patients develop bleeding manifestations (petechiae, bleeding at venipuncture sites, hemorrhage).
    • In the second week, the patient either experiences defervescence and improves, or worsens and dies of multiorgan dysfunction syndrome (DIC, anuria, liver failure).
    • Convalescence can be protracted, with arthralgias, orchitis, recurrent hepatitis, transverse myelitis, or uveitis. Uveitis is likely due to the large amount of antigen present in the convalescent stage. Interestingly, the virus can remain in seminal fluid through day 60 of the convalescent stage.—Susanne Medeiros

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    Does Anti-VEGF Therapy Induce Atrophy in Wet AMD?
    “It’s the elephant in the room,” said SriniVas Sadda, MD, speaking at the Friday Retina Subspecialty Day meeting. Does anti-VEGF therapy influence the development of atrophy in neovascular AMD?

    The major anti-VEGF trials identified significant numbers of study eyes without detectable atrophy at baseline that later went on to develop atrophy: 20 percent in CATT, 28 percent in IVAN, and 29 percent in HARBOR trials.

    To answer this question, Dr. Sadda and his colleagues conducted a post hoc analysis of the HARBOR trial, in which more than 17,000 images were reread by masked graders.

    They learned that atrophy rates were higher with monthly compared with as-needed (PRN) treatment in both CATT and IVAN, but drug assignment was not a consistent risk factor for atrophy. Cysts, atrophy in the fellow eye at baseline, and absence of subretinal fluid were risk factors for developing geographic atrophy in the HARBOR trial.

    But it’s still too early to answer the big question, Dr. Sadda said. More study is planned, including developing a consensus on the optimal methods for identifying atrophy, additional analysis using a multimodal approach including OCT, and longitudinal quantitative analyses based on growth of lesions, not just presence of atrophy.

    “Should my treatment of patients change based on these data? So far, probably not. We do know that visual acuity gains do occur in the presence of atrophy, at least at two years.”—Susanne Medeiros

    Dr. Sadda is a consultant to Alcon, Allergan, Carl Zeiss Meditec, Genentech, Optos, Regeneron, and Roche; and receives research support from Allergan, Carl Zeiss Meditec, Genentech, and Optos.

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    Best Papers
    During today’s Original Papers sessions, the expert panel moderating those presentations named the paper they rated most highly. These Best Papers are as follows:
    • Cornea. Aganirsen Antisense Oligonucleotide Eye Drops Inhibit Keratitis-Induced Corneal Neovascularization and Reduce Need for Transplantation: The I-CAN Study, presented by Claus Cursiefen, MD
    • Glaucoma (Part 1).Reading Performance in Glaucoma Patients With 20-20 Visual Acuity, presented by Aron Barbosa Caixeta Guimaraes Sr., MD
    • Glaucoma (Part 2). Glaucoma-Related Adverse Events After Cataract Removal in Infancy: Outcomes at Age 5 in the Infant Aphakia Treatment Study (IATS), presented by Sharon F. Freedman, MD
    • Ocular Tumors, Pathology. Comprehensive Polymerase Chain Reaction Assay for Detection of Pathogenic DNA in Orbital Lymphoproliferative Disorders, presented by Yoshihiko Usui, MD
    • Orbit, Lacrimal, Plastic Surgery. Not available at time of publication.
    • Pediatric Ophthalmology. Evaluation of an Image-Based Reference Standard for ROP Diagnosis, presented by Michael Ryan, MS
    Tomorrow, there will be Original Papers sessions for Refractive Surgery and Retina, Vitreous.

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    Want More Program Content? Buy AAO Meetings on Demand
    AAO Meetings on Demand brings you more than 200 hours of online content from AAO 2014 and Subspecialty Day. Watch full-motion videos of the eight Subspecialty Day meetings and highlights from AAO 2014 on your own schedule, at your home or office.
    Where to buy AAO Meetings on Demand.
    On Tuesday, it is available for sale in the Academy Resource Center (Booth 508) until 1:00 p.m. and at a sales booth in the Grand Concourse until 6:00 p.m. After AAO 2014 is over, you can buy it online.

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    The Quotable Cataract Surgeon
    “That’s the last thing I’d do,” said Eric Donnenfeld, MD, disagreeing with the audience recommendation to perform a multifocal IOL exchange in a patient with a possible tear.

    “It’s really a ticking time bomb at this point,” said Nick Mamalis, MD, on the urgent need to remove an IOL from a patient with recurrent microhyphema, even though the IOL was in her good eye.

    “Don’t procrastinate—fix it,” said Roger Steinert, MD, on the need to solve the issue of a malpositioned toric IOL.

    “As late as you can, but as soon as you need it,” said Robert Cionni, MD, on the question of when to use capsular support.

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    Guest Medical Editor:
    Arun D. Singh, MD

    Managing Editor:
    Chris McDonagh

    Patty Ames, Peggy Denny, and Susanne Medeiros

    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 AAO 2014 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.

    If you would like to update your email address or be removed from the mailing list, send a request toeyenet@aao.org. Questions? Comments? Email Chris McDonagh at cmcdonagh@aao.org.

    ©2014 American Academy of Ophthalmology. All rights reserved.

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