COMMENTARY

Advances in the Past 20 Years of Ophthalmology

Perspectives From Wills Eye Hospital

Julia A. Haller, MD; Mark H. Blecher, MD; L. Jay Katz, MD; Carl D. Regillo, MD; Christopher J. Rapuano, MD

Disclosures

October 20, 2015

Editorial Collaboration

Medscape &

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The Past 20 Years in Cataract and Glaucoma

Julia A. Haller, MD: I'm Julia Haller, ophthalmologist-in-chief at Wills Eye Hospital, and I am here in the Wills Eye Alumni Society newsroom with my colleagues from the hospital. This is a collaboration between Wills Eye Hospital and Medscape in honor of their 20th anniversary. We are here to talk about our perspective on what has been happening in the past 20 years in ophthalmology.

Let's start out with cataract surgery. I have Dr Mark Blecher here from our cataract and primary eye care service.

Mark H. Blecher, MD: The past 20 years have been really exciting in cataract surgery. Cataract surgery is the number one surgical procedure performed in the United States. It has become more dependable and safe, and we have been able to achieve much better visual results than we ever could before. The advent of small-incision cataract surgery, continued outpatient surgery, topical anesthesia, and the ability to correct not only the opacity that is the cataract but also the patients' refractive errors to free them from wearing glasses have all been major advances.

Dr Haller: Fantastic. I have Jay Katz here from our glaucoma service. Dr Katz, what has been new in the past two decades in glaucoma?

L. Jay Katz, MD: We have had some landmark studies that have really validated what we do in glaucoma, in particular showing that lowering intraocular pressure (IOP) makes a difference.

We've also identified risk factors for managing glaucoma patients, such as findings from pachymetry, which have become a mainstay in terms of the evaluation and treatment of patients. With medical therapy, we have had the introduction of prostaglandin analogues, which have become the primary therapy for most of our patients, and the introduction of fixed-combination products to help with compliance issues, which is always an issue with a chronic disease like glaucoma.

Finally, we have branched out into surgery and have made it more effective, with antimetabolites being a regular adjunct in filtration surgery. With minimally invasive glaucoma surgery, we have yet another series of operations that can help a certain segment of the population.

Dr Haller: What about in terms of diagnostics, Jay? Carl and I have been talking about it in retina. Have there been any advances there?

Dr Katz: Yes; I think that technology has been a huge boon for us in terms of perimetry and computerized perimetry, and getting smart algorithms to help us make the test faster and more palatable for our patients. We have all really understood the benefit of multiple testing and looking at progression over time (eg, slow progression vs fast progression), and that has been important not only for perimetry but also for imaging technology, as we have a very strong connection between structure and function in glaucoma.

Dr Haller: That is probably true for you, too, isn't it, Mark? You have seen a lot of diagnostic developments and high-tech equipment that you use now that you didn't use 25 years ago?

Dr Blecher: Absolutely. To get the kind of results that patients really expect from cataract surgery, we need a great degree of precision in calculating the intraocular lens (IOL) power and having optical biometry and better ways of imaging the cornea—both the anterior and posterior surfaces of the cornea. Now we know that the posterior surface of the cornea is also important for calculating IOL power, and for addressing astigmatism correction.

We have a wonderful range of instruments that can give us a lot more data, and it is a matter of getting our arms around all of this. Sometimes it is almost too much data, but it has been really great, and it has resulted in vast improvements in the outcomes of cataract surgery for just about every patient.

Advances in Retina and Cornea

Dr Haller: Great. Carl Regillo is here from our retina service. Carl, what would you point to in terms of the past two decades of progress?

Carl D. Regillo, MD: There is actually a lot to talk about. Looking back 20 years ago, I never would have dreamed that we would have made the progress we have made in retina, particularly in diagnostics, therapeutics, and surgery. In diagnostics, there is optical coherence tomography (OCT), which has been a tremendous resource in the diagnosis and management of major retinal disorders. That is clearly top of the list on the diagnostic side.

On the therapeutic side, the major retinal diseases and leading causes of blindness, in particular wet age-related macular degeneration (AMD) and diabetic retinopathy and diabetic macular edema, have completely been revolutionized with anti-vascular endothelial growth factor (VEGF) therapy. We actually started with photodynamic therapy as the first major advance, from all we had before being laser. Pharmacotherapy with anti-VEGF agents has really been an extraordinary change. Patients are now, on average, improving vision in wet AMD, and that was never accomplished in the past.

Finally, there is the surgical front. We went from 20-gauge large instrumentation to microsurgical techniques, like our colleagues in cornea and in cataract extraction, so we have small incisions. We now have sutureless vitrectomy, which is more efficient, has faster recovery, and probably has better outcomes. Along with that are some other intraoperative devices and technologies that have improved the way we can do our surgery, mainly wide-field viewing and certain products, such as perfluorocarbon liquid, which have come to market and are now in our hands on a regular basis.

Dr Haller: How about lasers?

Dr Regillo: Yes; we went from big, old-fashioned tube technology to lasers the size of this table down to lasers weighing 5 lb. The laser essentially does the same thing, but the portability and reliability of lasers is much improved.

Dr Haller: And the ability to automate, to scan, and do targeted laser.

Dr Regillo: Sure, and that is also the next step, which is really taking the automated part and fine-tuning it.

Dr Haller: Great. Chris, we have left the front of the eye for last, but there is very explosive growth in options for cornea.

Christopher J. Rapuano, MD: There have been numerous advances in the field of cornea over the past 20 years. For maybe the first 100 years of corneal transplants, 99% of the transplants that were done were full-thickness transplants, where the entire cornea was transplanted. About 10 or 15 years ago, we've made this move toward selective keratoplasty, where only the damaged or abnormal part of the cornea is transplanted. This started off with the front 95% of the cornea. It turns out that this is trickier, and the benefits are not quite as wonderful as when you do the back layer of the cornea. The vast majority of corneal transplants are done for endothelial problems, in particular Fuchs dystrophy, where the front 95% of the cornea is totally normal and you can just peel off the back layer, put a new back layer on, and get it to stick.

This has made the whole field of corneal transplantation vastly different. In fact, as of about 1 or 2 years ago, more than one half of the transplants done in the United States are done with a back-layer surgery, either Descemet stripping endothelial keratoplasty (DSEK) or Descemet membrane endothelial keratoplasty (DMEK). The recovery is much faster (ie, within a couple of months), as opposed to 1 or 2 years or even longer for full transplants. There is also less rejection, ideally less glaucoma, better quality of vision, and much less change in the refraction. Refractions with full-thickness transplants are rather unpredictable postoperatively—nothing like modern cataract surgery, where you can hit it on the button. With DMEK or DSEK, it changes very little, with very little induced astigmatism, so the visual results are much better.

Dr Haller: Wow. How have technological advances in diagnostics shifted in the past two decades?

Dr Rapuano: As Mark mentioned, we've had cornea imaging for almost 30 years, but those techniques have gotten much better with anterior topography, and now we have posterior imaging. There are ultrasonic waves with ultrasound biomicroscopy or with high-frequency ultrasound to actually measure epithelial thickness. There are now methods where measuring epithelial thickness may actually predict or be able to diagnose keratoconus at a much earlier stage. OCT in the back layer and Scheimpflug photography can also tell us when there is a posterior corneal abnormality, which is probably the first sign of keratoconus. You would like to know whether a patient has it, but also you want to avoid or change refractive surgery options for patients with keratoconus.

Dr Blecher: Chris, what about corneal hysteresis—are you finding that helpful or interesting?

Dr Rapuano: Corneal hysteresis is a way of measuring the elasticity and, in theory, the strength of the cornea. We were very hopeful maybe 10 years ago when that technology came out, and we bought a machine. We unfortunately have not been overwhelmed with how helpful it is in differentiating keratoconus from nonkeratoconus. There are definitely normal results, there are definitely abnormal results, but there is a big gray area in the middle. We are still using it. The technology and software have improved, so that may be the way of the future, but right now it is still in evolution.

Dr Haller: Chris, you were quoted in the Wall Street Journal[1] the other day about corneal infections. Are there new infections, or are they the same as they have always been?

Dr Rapuano: I think the infections have been around for a long time, whether it is fungal keratitis or Acanthamoeba keratitis. I think that doctors are doing a better job of diagnosing many of these. I think a lot of Acanthamoeba keratitis was undiagnosed in the past, and people ended up either losing their eyes or having transplants. I think we are better at that now.

There are more contact lens wearers these days, and I am not sure all contact lens wearers are using their contacts appropriately, so there is a question of whether we are having more ulcers. Contact lens care is extremely important. Poor contact lens care and overnight wear of contacts are major risk factors for corneal ulcers. Corneal ulcers can be absolutely devastating to the eye and to vision.

What Does the Future Hold in Ophthalmology?

Dr Haller: Speaking of news media, I saw a picture of you in US News and World Report[2], Jay. Where do you think glaucoma is going? What are the challenges, both in terms of taking care of everybody and specific methods of treatment looking forward?

Dr Katz: We face some challenges in the coming years, in particular with glaucoma, because we have an aging population. Our best estimate is that there is going to be 50% more glaucoma in the community over the next 10 years. We are going to have a manpower crunch. We are going to have a difficult time identifying and treating everybody.

It turns out that maybe 50%-75% of individuals with glaucoma in our country are undiagnosed, so there are going to be innovative ways of reaching out and trying to capture that population who has disease—hopefully before they become too far advanced, because we don't know how to reverse it yet. Telemedicine may be a very interesting way of trying to reach out to more patients and trying to diagnose glaucoma early. That is very exciting, and that is one avenue that I think is going to be explored in future years.

In terms of treatment, I think we have to reexamine how we are treating patients, and exhausting 5 or 6 medications is probably not the way to go. I think we are going to have better drug therapy, maybe even better delivery of drugs, because of the many compliance issues. Dosage forms other than drops, such as external devices or injections, will be helpful for glaucoma.

Finally, with surgery, we are still evolving and getting newer surgical techniques. Microincisional glaucoma surgery encompasses a whole spectrum of different operations that all look very promising as another way of operating on our patients. I think it is pretty exciting. We have a lot of room to improve, and a lot of opportunities in glaucoma.

Dr Haller: Carl, what are the exciting challenges in retina?

Dr Regillo: Despite the great advances, there are certainly unmet needs, and I think it is highly likely we are going to address these unmet needs pretty effectively over the next 5-10 years. For dry AMD, a disease we can't do much for, I think there is likely going to be small-molecule biologic, even potentially stem cell, therapy to help our patients. For retinal degenerations, it is looking like gene therapy could be in our very near future.

Dr Haller: And we now have retinal implants. The Argus® implant (Second Sight Medical Products, Inc; Sylmar, California) was approved recently.

Dr Regillo: That is right. The Argus implant is another major, recent advance, and I think that technology is going to carry forward and become better refined.

In terms of drug delivery, we have got to get beyond the frequent monthly injections, and hopefully there will be sustained-release formulations that will be very useful for our patients in retina and for pretty much any area of ophthalmology.

Dr Haller: Mark, what are you looking forward to that is exciting in your next 5-10 years of practice?

Dr Blecher: Cataract has always been an interesting area. Going forward, I think the area that we are going to be focusing on is how to be more precise for every one of our patients. You can do great surgery on any given patient, but you want to know that you can walk in and do absolutely perfect surgery on every single patient.

In that regard, automation and technology will help us. We are working here at Wills with laser cataract surgery, which a lot of people are excited about because it can deliver precision capsulotomies, lens softening, and arcuate incisions to correct astigmatism. This benefits from three-dimensional OCT that it does on the fly in about 5 seconds. It is quite impressive to see the scans. Once you have got the cataract out, having newer lens technologies that not only correct preexisting refractive error but also restore accommodative or pseudo-accommodative ability so that patients don't have to depend on reading glasses (even after perfect cataract surgery) would be highly beneficial.

We are starting to get there. We are seeing multifocal lenses and extended range-of-vision lenses, which have been approved in Europe and Latin America. I was just at the European Society of Cataract & Refractive Surgeons meeting in Barcelona, and my colleagues there who are not laboring under the US Food and Drug Administration restrictions are very excited about some of these new products that will hopefully be here in the United States shortly.

Dr Haller: There are lots of exciting things in the past two decades, and lots of excitement ahead. Thank you very much for tuning in. This has been a collaboration between Wills Eye Hospital and Medscape. On behalf of all of my colleagues here at Wills, we congratulate Medscape on 20 great years.

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