Roger F. Steinert, MD; Eric D. Donnenfeld, MD; William W. Culbertson, MD; Richard M. Awdeh, MD; Ronald R. Krueger, MD


November 03, 2011

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Roger F. Steinert, MD: Hello. I am Dr. Roger Steinert, Director of the Gavin Herbert Eye Institute and Professor and Chair of Ophthalmology at the University of California, Irvine. It is my pleasure to welcome you to Medscape Ophthalmology Wrap-up for the American Academy of Ophthalmology (AAO) 2011.

I am joined today in Orlando by Dr. Eric Donnenfeld. Eric is Clinical Professor of Ophthalmology at New York University Medical Center.

Dr. William Culbertson (known as Bud) is Professor of Ophthalmology at the University of Miami, Miller School of Medicine, and he is also Director of the Cornea Service and Director of Refractive Surgery at the Bascom Palmer Eye Institute in Miami.

Dr. Richard Awdeh, sitting next to Dr. Culbertson, is an Assistant Professor of Clinical Ophthalmology and Director of the Technology Transfer Program at the Bascom Palmer Eye Institute in Miami.

Finally, we have Dr. Ron Krueger, who is Medical Director of Refractive Surgery and Professor of Ophthalmology at the Cole Eye Institute, Cleveland Clinic.

Welcome, gentlemen. In this wrap-up, we would like to hear from each of you about some of the exciting presentations at the meeting. I will start with Eric. Eric, what was your take on the meeting? What do you think is new and innovative?

A Technology-Driven Specialty

Eric D. Donnenfeld, MD: So much is new in ophthalmology. More than ever we are a technology-driven specialty. One thing that I found very interesting was the overview on femtosecond cataract surgery.[1] I really enjoyed seeing the WaveTec ORA System™ (WaveTec Vision; Alisa Viejo, California), which is an intraoperative aberrometer that fits onto the operating microscope and allows the surgeon to do real-time intraoperative aberrometry to see the refractive effect of cataract surgery. This gives real-time intraocular lens (IOL) selection for the surgeon, enabling the optimal IOL and reducing the risk of having to do enhancements and to nail your postoperative refraction. We are using this now routinely to adjust and titrate the limbal relaxing incision on patients who are having femtosecond cataract surgery. We use it on patients who are having toric IOLs, and we are also using it on patients with femtosecond arcuate incisions and titrating the incisions to adjust cylinder and achieve optimal visual performance. This is a great new technology. It's gaining momentum, and I was very impressed by that.

Collagen cross-linking is finally coming of age in the United States. The idea of combining UV light and riboflavin and stopping the progression of ectasia and keratoconus to give patients normal lives with normal corneas is exciting. The new advances that we heard about at this meeting included epithelium on riboflavin/UV cross-linking, and reducing the time of UV exposure from 30 minutes to 5 minutes or 3 minutes by increasing the wattage of the UV light. So, we have a lot of exciting advances to talk about here today.

Dr. Steinert: I agree. Certainly, there was a lot of focus on optics and optical performance as well as enhancing the visual performance of the eye. The cross-linking area has a life unto itself now, and it has finally taken off in the United States, even to the point that people are proposing to do it routinely with LASIK. It will be interesting to see what happens with that.

Earlier, we had a separate panel discussion on femtosecond laser refractive cataract surgery with Dr. Krueger and Dr. Culbertson, for viewers who want to delve into that subject in detail.

Today we are going to focus not on femtosecond refractive surgery itself, but rather other innovations. Just as we predicted, femtosecond refractive surgery is a type of "disruptive technology" that will lead to many other innovations in practice that have not previously been considered or are simply dormant.

You mentioned the WaveTec unit and the major step forward with the evolution from ORange to ORA. All of these things are going to come together and help us take better care of patients in ways that were hard to imagine just a few years ago.

Another example is astigmatic keratotomy. That has been around for a long time, but what about intrastromal, which can only be accomplished with femtosecond lasers?

William W. Culbertson, MD: Only a femtosecond laser can perform intrastromal keratotomy, so we know that it is effective. We know that it can be done very precisely at very prescribed optic zones and arc lengths and depths. We don't know, particularly, what angulation of the incision is optimal, but we do know that it can be very effective for treating smaller amounts of astigmatism, which, of course, are very important in situations such as a premium IOL or in monovision where we want to make the distance eye as perfect as it can be. It is a very important tool about which we will find out more as time goes on.

Dr. Steinert: How does this work? We all thought that we made cuts in the cornea; they opened up; epithelium came in; and that was what changed corneal curvature, with radial keratotomy and astigmatic keratotomy. So here we are doing something that is virtually invisible a week later at the slip lamp, and yet achieves permanent changes.

Dr. Culbertson: However astigmatic keratotomy is done, it basically is an additive procedure. It is as if we added more cornea in that dimension and, of course, that creates a flattening effect. If we actually make the intrastromal relaxing incision in the anterior three quarters of the corneal stroma, it appears to produce a flattening effect, although more modest than if it broke through to the surface. It seems that if we make the incision a little more posteriorly in the cornea, it is possible that it could create a steepening effect in that meridian, so we can envision a time when we might be able to make even circumferential or elliptical incisions that can steepen the cornea, or intrastromal radial incisions that could flatten the cornea. All of this needs to be worked out, but the femtosecond laser gives us the tool to do so.

Another interesting technology that has evolved and is maturing now, and is probably ready for general clinical use, is the intraoperative registration of a prescribed preoperative astigmatism axis. This allows you to use a photograph obtained at the time of IOL biometry, import it into a computation and overlay at the time of surgery that can provide the exact axis of treatment intraoperatively, and a capsulotomy position that may be related to a preoperative, undilated pupil position.

So we have these options. We are not sure how all of these will work together, but certainly, they will lead to better optical and refractive results in the long run.

Changing the Game With Imaging

Dr. Steinert: There are a lot of companies pursuing that.

While we're on that imaging theme, who's used SMI (SMI Surgery Guidance™; SensoMotoric Instruments; Teltow, Germany)?

Dr. Culbertson: I have used SMI.

Dr. Steinert: You are an SMI fan. At the European Society of Cataract and Refractive Surgeons (ESCRS) in Vienna, Zeiss launched their Callisto system (Carl Zeiss AG; Oberkocken, Germany) which, by the time it works its way through the US Food and Drug Administration here they anticipate having at ASCRS [American Society of Cataract and Refractive Surgery] in the spring. This system has one advantage. The concept is that it will capture an image of the eye at the time the IOL Master is used, particularly emphasizing the blood vessels. That image can be registered over the optical image at the time of surgery and will be displayed on the video screen in the operating room. The information will be imported backward into the microscope itself through the beam splitter, so the surgeon looking through the microscope will see the alignment marks and the desired axis where he or she wants to put the astigmatic keratotomy and the length of it or into the toric IOL.

Dr. Culbertson: You can see where some of this is going, and how this might be integrated into a femtosecond cataract laser system for precise orientation of the astigmatic axis, even in real time. This is all coming together. We don't know yet the best procedure to use, but all of it is aiming for one thing, which is better postoperative refractive results.

Ronald R. Krueger, MD: That is the focus in cataract surgery now, developing better tools for measurement and treatment, but we are also going to see that in other aspects of ophthalmology. The innovations in refractive surgery are going to spill over into the other areas.

Imaging is really important. More attention is now on Scheimpflug imaging for looking at preoperative keratoconus and posterior elevation and so forth. Even more recently, optical coherence tomography (OCT) is becoming more robust to the point that we can actually come up with epithelial thickness maps and be able to tell a lot about a cornea by just looking at the thickness of the epithelium. Maybe we will be using that in surgical treatments in the future.

Presbyopia is still a big interest. In fact, use of corneal inlays as a future modality for restoration of vision in presbyopia was getting a lot of attention at this meeting.

Converging Technologies in Ophthalmology

Dr. Steinert: It is fascinating to see technologies that we hear vaguely about for a few years and wonder whether they are ever going to take off, and then the planets align, in a sense. It really does take the convergence of several technologies to launch something into mainstream applications.

Dr. Krueger: Every technology has its moment, and it may be that it was ahead of its time, and then all of a sudden the time comes when it really can rise and progress.

Dr. Donnenfeld: That is exactly what is happening right now. There is an inlay called AcuFocus Kamra™ (AcuFocus; Irvine, California) and it worked very nicely. Now, when we add femtosecond technology to make the flap, and then centration with SMI, all of a sudden you can place the AcuFocus implant in exactly the right location, and the results have just improved dramatically. So you are absolutely right. It is technology coming together that is allowing us to create better refractive outcomes. There are many examples.

Dr. Steinert: That is true for the other inlays: the hydrogels, the Presbia FlexiVue (FlexiVue Microlens®,; Los Angeles, California), and the PresbyLens™ (Vue+, ReVision Optics; Lake Forest, California). All 3 of these technologies need very precise centration, which is trickier than it sounds. You think you just look through the microscope and know where to put it, but it doesn't work that way.

Dr. Donnenfeld: Absolutely.

Dr. Steinert: Combine that with the technology for mathematically determining centration and the technology for making flaps better, and all of a sudden pieces are falling into place.

Dr. Donnenfeld: You mentioned one other technology. We are talking about optically aligning. A technology called TrueVision® (TrueVision Systems, Inc.; Santa Barbara, California), which we have just received, is a 3D visualization system. The surgeon no longer looks through the operating microscope. The surgeon wears glasses and looks at a screen, which provides a 3D visualization of the operative field. You can take an image preoperatively and overlay it on the screen so that you can look at the limbal vessels. It takes into account cyclotorsion, and you can actually put incisions onto the screen. With this 3D system and preoperative overlay, you can just follow that diagram and make your incisions exactly where you want them.

Richard M. Awdeh, MD: It is a great time in ophthalmology. But when you think about some of these things, they have existed previously. History repeats itself. The idea of a corneal inlay may have occurred back in the Chiron (Irvine, California) days, several years ago, but it takes another technology to come forward to drive that earlier technology, which may not have progressed. When you think about innovation, you think about types of innovation. You may think of a new sculpture vs chiseling away at the body of knowledge that you already have. By that I mean that if you have an arm on a sculpture, then you chisel the hand and the thumb and you refine a technology that already exists.

When you have a disruptive technology come forward, which we have now in ophthalmology, you see the changes in everything else. All of a sudden, you see the importance of image guidance and intraoperative aberrometry. You see OCT being important because the femtosecond cataract platforms will have an OCT device in them. One of the interesting talks I heard was about the ability to use OCT to figure out the keratotomy of the cornea because that will then drive where these arcuate incisions are placed rather than having a topography there.

Apps and Other Cool Stuff

Another place you see this technology that touches every generation from my side, to younger than me, to older than me is the App store. Here you take something that is totally innovative, new to the world, and it changes the way that we function. You can't imagine being at a meeting and not having an App on your smart phone to give you directions to get places and meet with people. This is a market that was nonexistent, and in 2 short years has become a multibillion-dollar market, and you can't remember life before it existed.

Walking the floor at this meeting we are starting to see the first wave of Apps that will affect ophthalmology and, specifically, Apps that help patients recapture control of their disease. Certain Apps will have Amsler grids so that, rather than coming in to the office every so often, patients with macular degeneration can monitor their disease at home. They will know when their disease changes. They will be alerted about when to contact their physician. Eventually, we can imagine a day when those Apps will notify the physician or patients' children or grandchildren that there is an issue and refer them back to the physician.

Dr. Steinert: I just got my new iPhone 4S, and it has voice recognition that not only functions amazingly, but it doesn't have to learn your voice. It is called "Siri," and if you ask it the meaning of life, it gives a bunch of funny answers. One of them is, "There's an App for that."

It really is pervasive; you see people walking around with their iPads during the meeting. I just downloaded the journal Ophthalmology, now available as an App from Elsevier. All of this is definitely having an impact on our lives, and all of these things do, in fact, converge. So what else is new?

Dr. Culbertson: A very interesting technology is the femtosecond intrastromal lenticular extraction. You use a femtosecond laser to create a posterior plane and a curved anterior plane in a small angular access channel to go in and remove the lenticule, thus preserving the anterior 120 µm of the corneal stroma as well as preserving a large proportion of the anterior corneal nerves. It has the potential to give good results with fewer neurotrophic issues with the cornea postoperatively, like we can see in LASIK, and to preserve the strongest part of the corneal anatomy and collagen structure in the anterior 120 µm. It appears to have been developed to the degree of accuracy that approaches LASIK. That has to do with learning about how the femtosecond laser works and some of the imaging and registration techniques that have developed in the last 10 years since the femtosecond laser has been developed.

So I am looking forward to that. It's not approved in the United States, but reports are coming in from other countries including Egypt, Holland, Denmark, Thailand, and India. They all are reporting excellent results, so I look forward to that developing and knowing more about it.

Dr. Krueger: The advantage is not just the biomechanical preservation by making a small incision to remove the lenticule, but the fact that you are putting all these pulses in internally without exposure to the atmosphere, and there are fewer changes from hydration and so forth. In high myopia, for instance, you will probably see greater predictability even than what we might see with LASIK in the future. Technology is pushing us forward by improving things incrementally.

New Horizons

Dr. Donnenfeld: I would like to expand our universe here. We are a bunch of cornea, refractive, and cataract people. What I see as really disruptive and changing everything is the innovation of microinvasive glaucoma devices. A device made by Glaukos Corporation (Laguna Hills, California) is on the verge of approval, and they have presented some wonderful data on the ability to place these microinvasive glaucoma devices, the smallest technology ever seen in human beings, that will allow surgeons to place small drains through the trabecular meshwork and into Schlemm's canal to control glaucoma. This technology will change the way general ophthalmologists look at glaucoma and make this a mainstay of therapy, where the average cataract surgeon will not only do cataract surgery in patients with glaucoma, but insert these devices and possibly provide better control of glaucoma and eliminate the need for patients to use glaucoma drops for the rest of their lives. This is the first edge of a wave of new devices that are coming that I think will be exciting for all of us.

Dr. Steinert: I agree. At this meeting I heard not only about the imminent approval and release of the Glaukos stent, but multiple other devices are very close as well. It is kind of interesting to see a field that for years seemed to be doing nothing new, suddenly exploding. At this meeting I heard of 2 different ways that they are trying to do constant monitoring of IOP. One is a contact lens that measures flexing and allegedly can track tension that way. There is an implantable tension device as well, and the sustained-release drug delivery systems that are at least really close to major clinical investigation after being just a promise for so many years.

Another example of how technology can transfer came from pediatric ophthalmology at this meeting. One of the big buzzes was that they are organizing a national study funded by the National Institutes of Health to look at how refractive surgery for high ametropia can change the lives of challenged kids. Evelyn Paysse[2] gave a great presentation and some case studies of children who are severely out of focus. You can't even get a contact lens in these children; they are increasingly isolated and being deprived of visual input. Dr. Paysse showed a great video that showed, through 3D focusing techniques, what this is like for children. She gave a case presentation about how much a child's behavior improved after that child underwent refractive surgery. A couple of centers are gearing up for the challenges of doing this in children with special needs, with sedation and all. However, it never would have happened if we hadn't started with refractive surgery, and now here it is in pediatric ophthalmology.

Dr. Donnenfeld: Refractive surgery is perceived by some individuals to be a cosmetic procedure, but clearly it is not. This is a therapeutic application that improves a patient's quality of life, and improves their visual function in many ways. It goes beyond pediatrics. It goes to almost every aspect of what we do: the ability to drive safely at night and the ability for soldiers to function in an unfamiliar environment. Refractive surgery is a mainstream procedure that is really important for all ophthalmologists to appreciate.

Dr. Steinert: What about high toric IOLs? The companies resisted that for the longest time, saying that this was a tiny market; we don't want to put the resources into it. As a corneal surgeon, I'm sick and tired of corneal transplant cripples. They have nice clear transplants, and they can't function, or they are dependent on a rigid contact lens. With customized topography and Wavefront-guided LASIK combined with toric IOLs, that should stop. That should be the end of that, and it's going to be very exciting.

Dr. Donnenfeld: I couldn't agree with you more. The new toric lenses that treat higher levels of astigmatism, certainly with more coming, will really change the way I look at penetrating keratoplasty. I am very comfortable recommending to patients who have significant refractive errors, both sphere and cylinder, that with even a minimal cataract they are best served by taking the lens out and solving their refractive error with an IOL. The results are fantastic.

Dr. Steinert: Well, Dr. Krueger, Dr. Awdeh, Dr. Culbertson, and Dr. Donnenfeld, thank you very much for this terrific discussion and for joining us tonight. I'm Roger Steinert for Medscape Ophthalmology Insights. See you next time.