AAO 2012 Wrap-up: Taking Ophthalmology to the Next Level

American Academy of Ophthalmology 2012

Roger F. Steinert, MD; Bonnie A. Henderson, MD; Stephen S. Lane, MD

Disclosures

November 21, 2012

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The Buzz at AAO 2012

Roger F. Steinert, MD: Hello. I'm Dr. Roger Steinert, Director of the Gavin Herbert Eye Institute and Professor and Chair of Ophthalmology at the University of California, Irvine. It's my pleasure to welcome you to the Medscape Ophthalmology wrap-up for the American Academy of Ophthalmology (AAO) 2012 meeting.

I am joined today by Dr. Steven Lane, Adjunct Professor at the University of Minnesota, and Dr. Bonnie Henderson, Assistant Clinical Professor at Harvard Medical School. Thank you for taking time out of your busy schedules to join us.

We want to talk about the highlights of the meeting, including some of the more exciting things that we have heard on the trade floor and in presentations, symposia, and the evening festivities, where we often learn the most.

The first impression that we all shared is that there was a remarkably upbeat attitude and spirit of the meeting, despite an economic pressure situation that would not necessarily justify the positive feelings. What are your thoughts about that, Bonnie?

Bonnie A. Henderson, MD: I absolutely agree. Even with the economic downturn, in medicine it's a very different field, and we are relatively untouched by economics. We are very excited with all the new innovations in ophthalmology, and we are able to provide care in better and more efficient ways, even with the economic downturn.

Stephen S. Lane, MD: As you walk the exhibit floor, there is a certain buzz, and it's not necessarily from the big companies from whom we are used to seeing innovation. We are seeing a lot of innovation from small start-up companies that have tremendous technology and potential. These are the really exciting things that we look forward to. Ultimately, who knows, they may be bought up by some of the larger companies -- the big names in ophthalmology. Our colleagues are encouraged that these technologies have the potential to help our patients get better results and be able to live happier, more fulfilled lives, and that's exciting.

Dr. Henderson: Some of that happens because the physicians are seeing patients on a daily basis, and they come up with innovative ideas regardless of what is happening outside of their office. So if they find a better way to deliver a service -- let's say they find a more efficient way to operate -- they are able to pursue that and make advances, and they are very excited about the new changes.

MIGS: Not Just for Glaucoma Specialists

Dr. Steinert: Let's turn to one of those changes, which this is year is microincision glaucoma surgery (MIGS): technology that is not just for the glaucoma specialist but also for the general cataract surgeon. What do you think about MIGS?

Dr. Henderson: MIGS is very exciting because it's a real combination of the different fields. Previously, cataract surgeons did cataract surgery, and glaucoma surgeons did glaucoma surgery, but now they have been combined, similar to the changes with refractive and cataract surgery. The 2 fields are colliding, and if we are able to offer different types of noninvasive and simpler procedures that actually deliver results, then it's a very exciting change in the types of delivery of care systems that we can provide.

Dr. Lane: Glaucoma has traditionally been a very frustrating condition to treat. Eye drops have been the mainstay of treatment for many patients for many years, and there isn't anything that actually cures glaucoma. The best thing you can do is to continue to put it off. When selective laser trabeculoplasty and other laser-based procedures came along, we started to see a shift in glaucoma from being a medically-treated disease to one in which some surgical intervention was taking place, but the treatment responses were usually short. Patients still had to be supplemented with drops, and surgical procedures were reserved for when the patient was crashing down, an end-stage situation.

The minimally invasive glaucoma stents give us a procedure that can be done by non-glaucoma specialists as part of routine cataract surgery, and which can be very effective. We now have a real surgical procedure that gives better results and has the potential of reducing patients' need for or number of medications, which is a life-changing event for many of these people and allows them more freedom.

Dr. Steinert: MIGS, at least with current devices, works best for people with early glaucoma, by stabilizing pressure and reducing the problems of compliance. Many studies suggest that the only time the patient uses the drops regularly is the day before coming to the doctor's office. Can we keep people at the early stage of glaucoma and not see progression? That has been a frustrating issue in management of glaucoma from the beginning. It has never been solved.

Dr. Henderson: Absolutely. This procedure can be done in conjunction with cataract surgery. This is very nice for the patient because they undergo only 1 surgery, and have the benefit of improving vision from the cataract procedure and reduced pressure from the glaucoma procedure.

Dr. Lane: We have the potential (at least from some of the early data and some data presented here at AAO) for placing more than one stent for a greater effect. Whether multiple eye stents are placed at the same time, or the patient comes back for another minimally invasive procedure to add a second or third stent, this adds to the potential for this procedure. There is a lot of excitement about this.

Dr. Steinert: Ike Ahmed presented data[1] that look compelling for 2 and 3 shunts. Because the drainage channel is not 360° anyway -- it is quadrants -- it makes sense that as many as 4 stents could make a big difference.

Dr. Henderson: Much of the worry about glaucoma surgery is the fear of hypotony. With minimally invasive procedures, the risk for hypotony is almost zero. It really is great for the early glaucoma patients, and for cataract surgeons who don't delve into serious glaucoma procedures. This is a safe and effective method of improving the pressure.

Toric IOLs and Posterior Corneal Curvature

Dr. Steinert: Shifting gears to cataracts and intraocular lenses (IOLs), my impression was that we are not seeing any new technology other than the ongoing interest in femtolasers for cataract surgery. The machines are very refined. No new devices were introduced.

We know that many things are in the pipeline for IOLs but probably not coming out in the next year. One area of real ongoing interest and growth is the toric IOLs for astigmatism. Market Scope shows steady growth in that segment, and surgeons are becoming more comfortable with them, now that they are achieving good results with toric IOLs.

Steve, can you fill us in on some of the interest in and confusion about the work of Doug Koch and the role of the posterior cornea, and trying to understand why our results with toric IOLs are good but not great?

Dr. Lane: Doug Koch[2] did some very important work. It wasn't necessarily original, because we have known about the posterior corneal curvature for a long time, but Doug synthesized all the studies that go back 15 years and give us a better idea of the importance of posterior corneal curvature in the determination of corneal astigmatism. With toric lenses, if we don't take these important posterior corneal curvature issues into account, we can under- or overcorrect patients in terms of the amount of astigmatism that is present. Doug was able to generate some commonsense discussions about the direction and magnitude of posterior corneal curvature.

This concept will now be built into the calculators and tools that we will use down the line for the calculation of toricity. Doctors are starting to understand this concept. We never prescribe a pair of glasses without the cylindrical component as part of that prescription. Why in the world would we do cataract surgery and not fully correct the amount of astigmatism? It's easy to do. It's a concept that is starting to take hold.

Dr. Henderson: It answers a lot of questions. Many patients have residual astigmatism after toric implantation, and surgeons have wondered whether it was just a missed calculation of the corneal curvature, or that they put in the wrong lens power or implanted it improperly. Maybe some of that residual astigmatism is because they didn't take into account the posterior corneal astigmatism.

Koch's hypothesis is that because a posterior corneal astigmatism is adding against-the-rule astigmatism, then if you have a patient who has with-the-rule astigmatism, it will be counteracted by against-the-rule astigmatism. You are going to hold off putting in a toric lens until you see a greater amount of anterior corneal astigmatism. By building a nomogram into the toric calculator, we can adjust the amount of toric power that we are going to put in and have a much better outcome. The patient will see better after cataract surgery without the aid of spectacles.

Putting Toric Calculations Into Practice

Dr. Steinert: Have you started adjusting your toric powers?

Dr. Henderson: I have. I don't have a great nomogram because Doug is still perfecting it. For instance, if I am trying to determine whether I'm going to put in a power that is less or a power that is more in a patient who has with-the-rule astigmatism, then I am going to go with the lesser power. Conversely, if I have a patient who has against-the-rule anterior corneal astigmatism, I am going to err on the side of a higher-power toric lens. That has given me some guidelines when I am trying to decide between 2 powers. This is fairly new, from the Great Innovator's Lecture at the American Society of Cataract and Refractive Surgeons meeting this past spring.

Dr. Lane: Doug has done some great work, but the exact numbers are yet to be determined. I found myself being much too aggressive in correcting with-the-rule astigmatism in the past and couldn't determine why, and I found myself (not based on Doug's work, but empirically) reducing that amount without knowing why. Now I have a good explanation. We are talking about one half of a diopter. Younger cataract patients can shift against-the-rule with age, so you almost have a dual effect going on. You have the posterior corneal curvature that you have to keep in consideration, plus the fact that as they age, they are going to shift to against-the-rule, so it is still going to be an age-related nomogram down the line.

I tend to do exactly what Bonnie does -- use one half of a diopter as my stable point in terms of making that determination. So a patient, for example, with one half of a diopter of with-the-rule cylinder that I may have wanted to correct previously, I will absolutely leave alone and put in a spherical lens. I may end up going up a power on my toricity in an against-the-rule patient with maybe one half of a diopter measured, but actually more like 1 diopter or more as the lens of choice. None of our calculations fall right on the number zero, so we have to hedge one way or the other.

Dr. Steinert: I will be interested to see whether we start getting to the sophistication level where we actually use a topographer -- some of them do measure posterior corneal curvature. Perhaps we should start to pay attention to that, too. It does have the appeal of explaining why, if you take somebody from 4 diopters down to 1, you look like a genius, but when you are down at the low end and you are dealing with a 1-diopter correction, you are off, because of the posterior curvature.

The Value of Intraoperative Aberrometry

Dr. Steinert: A related issue is the increasing use and widespread acceptance of the value of intraoperative aberrometry. There have been some ongoing developments with the WaveTec ORA System™ (WaveTec Vision; Alisa Viejo, California), as well as a new device that is going to be available soon from Clarity Medical Systems (Pleasantville, California).

Steve, you have been a real guru of toric measurements and monitoring. What are your thoughts about these systems?

Dr. Lane: The idea of having a device on our microscope that we would use intraoperatively to help us determine an IOL power makes great sense. To find a better way to achieve emmetropia is a very important goal to me, and we can only do so much with theoretical formulas and measurements. We need better ways to come up with the real power of the eye.

Although many of the new formulas that have been developed and are being used are terrific and continue to show improvement, there is nothing like being able to do a measurement right at the time that you need it, to determine what that size is and be able to put in the lens that matches. Aberrometry is the future of how we are going to perform cataract surgery to get the very best results.

Granted, that is still in the future, but we have good data that suggest that we can do better with aberrometry than we have been able to do with the theoretical formulas. As a person who uses one of these on a regular basis, I find myself frequently changing the lens power on the basis of aberrometry from what I had intended to use when I walked into the operating room. The potential is great. It is wonderful that we have companies that are looking at this and improving their offerings. Both Clarity and WaveTec have changed their technology to make incremental improvements, and I am happy to be involved in this.

Dr. Henderson: This is especially important because of all the corneal refractive procedures we are doing. Approximately 5 million LASIK procedures are performed every year around the world, and all those patients, if they live long enough, are going to need cataract surgery. With that huge wave of patients who will be coming through, we need technology such as this to make sure that we nail the outcomes.

Furthermore, we have special lenses now. Before, we had just one type of lens: a monofocal lens. We didn't think about astigmatism, and the patients accepted that they needed glasses after cataract surgery. We didn't need all this fancy new technology; however, now, patients' expectations are higher. They expect to see perfectly after cataract surgery. They don't want to wear glasses for anything. They definitely don't want to wear them for driving. Many don't want to wear glasses to read or see their computers. So if we can offer perfect postoperative refraction emmetropically, that is the Holy Grail.

We always joke about that, but it is true. It would be nice to give the patients the freedom. It is not just a vanity issue; it is a freedom issue, being able to function without looking for glasses all the time.

Dr. Steinert: We invested in a wavefront aberrometer this past year, and we are very confident in its ability to help us with the basic power and in special situations, with refraction being the obvious one.

Sam Garg, my colleague at University of California, Irvine, experienced the ultimate in conundrums. A patient who had refractive surgery and then had corneal decompensation, had Descemet's stripping endothelial keratoplasty (DSEK), so now he has an element in the backside that is completely throwing everything off. Not only was he dealing with front-side problems, he had to figure out the sphere and cylinder power of the DSEK graft. He went to the operating room with a dozen lenses of different toricity and sphere, and then used the ORA system to decide which lens to use and nailed it. It was very impressive.

Dr. Lane: We all have patients in our practices who previously had penetrating keratoplasties, and also perhaps had corneal transplants in their youth for keratoconus or some other reason, and they have grown up having to wear rigid contact lenses to correct relatively high degrees of astigmatism and high spherical errors. They develop cataracts, and now with toric intraocular lenses and the use of aberrometry, we have the potential to take those patients out of glasses with a single operation, a single lens implant, getting it right the first time. It is a true game changer for those patients. It is exciting and fun to be able to take care of patients like that.

Dr. Steinert: With our interest in femtolaser incisions, we have been able to get sutures out (whether it is deep anterior lamellar keratoplasty or a penetrating graft) in less than 1 year. Once we get the sutures out, we deal with the lens problem. Those are usually the patients who have the most astigmatism, but it tends to be geometrically symmetrical, and with regular astigmatism, we are achieving less than 1 diopter in almost all of them. It's amazing, and they are the happiest patients around.

Trends in Smartphone Apps

Shifting slightly to a different version of imaging, something I heard about when walking around the exhibit floor was devices to let us use smartphones or tablets. You can hang the devices off of a slit lamp and get a pretty reasonable photograph. It won't be quite as good as one of the dedicated units, but it is quite serviceable, and now I am seeing a lot of apps.

My favorite app that I stumbled across was related to the toric IOLs. I had a postoperative patient with an issue about what position the lens was in, and I didn't have a single slit lamp that had a degree reading that allowed me to angle the beam. I realized that all I had to do was put that light beam on the axis of the toric IOL and hold up my iPhone® with this app that was basically a level. It was called iHandy, a free app. I twisted my phone to match up with the light beam. I knew down to one tenth of a degree where that lens was. It was pretty cool, but there are apps for vision testing and almost anything related to refraction.

Dr. Henderson: It's amazing that we are starting to use our phones to do some of our medical work. The camera on the iPhone that we can launch as a slit lamp is terrific because if you see an issue or a lesion that you would like to take a picture of, then you don't have to try to send the patient to a slit-lamp photography unit.

Dr. Lane: I'm guilty as charged. I saw an interesting patient who had a corneal issue, and I didn't know what it was, so I took out my iPhone and took a couple of photographs. I knew I would always have my phone with me, and I could grab my colleagues and say, "Have you ever seen anything that looks like this?" Sure, I could have taken the patient back to the slit-lamp camera and taken a picture, but then I would have to carry it around. I think we are going to see more of this.

Taking Care of the Ocular Surface

Dr. Steinert: Steve, you have been one of the thought leaders on the issue of the ocular surface and how it is affecting ocular performance, and particularly multifocal lenses. Can you tell us about the new technology for the ocular surface?

Dr. Lane: The ocular surface is something that people have pushed off to the side for many years. The patient with the itchy, burning dry eye has been frustrating, because there are so many of these patients and because our treatments have been dismal. We close our eyes and shake our heads when we see their names on the schedule. It is a very unhappy group of patients, but there are some neat things that will be coming available in the very near future that were discussed at this year's meeting.

Starting with some of the new preparations for eye drops, we are seeing a movement to the tear gel-type, higher-viscosity vehicles for some of our drugs (steroids, antibiotics, or nonsteroidal antiinflammatory drugs). We are seeing more of these drugs provided in vehicles that are much more friendly to the ocular surface, especially some of the preservative-free glaucoma drops.

Meibomian gland disease is a real problem that we see quite often in our cataract population. In these patients, we need to maximize the ocular surface so that we have a better chance of hitting our targets and having happy patients with better vision, and so any new treatments for meibomian gland disease are helpful.

TearScience (Morrisville, North Carolina) has come up with a mechanical method of providing lid hygiene for patients. It provides a source of heat on the underside of the eyelid with a little pressure on the eyelid. This essentially resets the meibomian gland.

When our computers crash, we shut them down and reset them. This is the same idea. We evacuate all of the glands with this device, and then it allows the gland to reset and start to work better again without the thick secretions. It is a nice in-office treatment that lasts 6-9 months or even longer in many patients with a single treatment. This obviates many of the treatments that we have used on a long-term basis, with poor compliance.

We are learning more about nutrition. To me, ketchup is a vitamin -- I am not a supplement person in general, but I have become an advocate for omega-3 fatty acids, especially those with triglycerides as one of the constituents. These can really help patients with ocular surface disease.

Dr. Henderson: Nutritional supplements have been emphasized over the past year. We thought that supplements were maybe just somewhat helpful, but not that beneficial, but studies are now showing that omega-3 fatty acids and flaxseed oil really do help. Besides the traditional lid scrubs and the warm compresses, some of the newer innovations for the tear film and the anterior surface will probably be beneficial and be more soothing, provide more lubrication, and result in better vision.

Collagen Crosslinking: Expanding Applications

Dr. Steinert: Collagen crosslinking has been of interest to the cornea specialists because of keratoconus and ectasia, but now Avedro (Waltham, Massachusetts) has been pushing other applications. They have developed a method of local treatment to influence the topography, and they are going to be introducing this topography-driven local crosslinking treatment over the next year, both to center cones and help with ectasia, and to influence the outcome of astigmatic keratotomy.

There is some talk that this should perhaps be used routinely after LASIK as a way of stabilizing the cornea and allowing more aggressive, higher levels of treatment. Are either of you interested in crosslinking studies?

Dr. Henderson: Itis frustrating that sometimes in the United States, we are not able to have some of the treatments that our colleagues in Europe and South America have. It is always very interesting to go to meetings in other countries and hear the results from crosslinking. It has been found to support the cornea and reduce the risk for ectasia, so the applications are very broad, and it is not just for keratoconic patients. The idea of preventing ectasia after LASIK surgery is very interesting.

Dr. Lane: As corneal specialists, we are just scratching the surface of what we will be doing with crosslinking in the future, both in terms of the mechanical applications of how we provide the treatment and what the indications are going to be for this technique. Unfortunately, all of these studies take a long time, and we are dependent on our European, Canadian, and Asian colleagues who are using this on a regular basis to give us information about how it can be used. It is tremendously exciting but at the same time frustrating, because it is going to be a while before some of these applications are in the hands of physicians who are not involved in the studies.

Dr. Henderson: We will benefit from the experience of our colleagues. They can tell us how long we should apply the medication, and whether to use epithelium on or epithelium off. They are working out some of the kinks for us, so we have to be grateful for our colleagues for conducting these preliminary studies.

Dr. Steinert: I would like to thank both of you, Bonnie and Steve, for taking time from your busy AAO meeting to come and chat about your impressions of this busy and active meeting. Thanks for joining us on Medscape Ophthalmology Insights.

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