December 1, 2017 Conference


am sesion Diagnosis and Management of Dry Eye and Ocular Surface Disease

Professional Practice Gaps:  The diagnosis and management of dry eye and ocular surface disease was identified as a practice gap from feedback from NEOS members and program committee review.

NEOS PROGRAM OBJECTIVES:

1) Present an overview of the Dry Eye Workshop Study 2 (DEWS2) report;
2) Educate attendees on how to incorporate new tests for diagnosing and classifying dry eye
3) Review ways to differentiate dry eye from other ocular surface diseases
4) Update attendees on current and emerging treatments for dry eye and ocular surface disease


Filaments, Fingerprints, and Floppy Eyelids - Dry Eye Cohorts
Gregory McCormick

Ocular surface dysfuntion is often multifactorial.  Treatment may be best when utilizing a "belt and suspenders" approach that improves tear film quality while managing associated co-morbidities.  A detailed assessment of eyelids, conjunctiva, tear film, corneal epithelium, corneal epithelial irregularity, anterior basement membrane dystrophy and salsmann's nodular degereration are all important parts of the ocular surface examination.  Appropriate management of these associated dry eye cohorts can improve both quality of vision and patient comfort and satisfaction.  Treatments include medical, surgical and behavioral modifications.  Clinical history is often as critical as clinical examination findings.  Several strategies will be discussed to manage these dry eye cohorts in order to optimize patient vision and comfort.


My Take on treatment of dry eye disease, Bugs, Drugs and Devices
Edward H. Jaccoma

In this lecture I will focus on my clinical approach to the "average" dry eye patient, with special attention to newer tools and techniques, including diagnostic devices and treatments, with a focused discussion of rosacea and Demodex. I also break down aqueous tear deficiencies vs MGD, discuss anti-inflammatories as well as the more MGD-specific Lipiflow and IPL treatments, Conjunctival Chalasis plications, my novel, off label RF dry eye treatment and dry eye patient "homework". 


TFOS Dry Eye Workshop II: Conclusions and recommendations.
David A Sullivan

Presentation_10_1206091934.pdf

To increase our understanding of dry eye disease (DED), the Tear Film & Ocular Surface Society (TFOS), a non-profit organization, launched the TFOS Dry Eye Workshop II (TFOS DEWS II) in March 2015. This initiative reflected the TFOS mission, which is to advance the research, literacy, and educational aspects of the scientific field of the tear film and ocular surface. The goal of the TFOS DEWS II was to achieve a global consensus concerning multiple aspects of DED. More specifically, TFOS DEWS II sought to: 1) Update the definition and classification of DED; 2) Evaluate critically the epidemiology, pathophysiology, mechanism, and impact of this disorder; 3) Develop recommendations for the diagnosis, management and therapy of this disease; and 4) Recommend the design of clinical trials to assess future interventions for DED treatment. This initiative, which took more than 2 years, involved the efforts of more than 150 clinical and basic research experts, who utilized an evidence-based approach and a process of open communication, dialogue and transparency. The entire TFOS DEWS II report was published in the July and October 2017 issues of The Ocular Surface. A downloadable version of the documents and additional material, including videos of diagnostic and management techniques, are available on the TFOS website: www.TearFilm.org


Tear volume based approach to classify tear dysfunction
Stephen Pflugfelder

Tear dysfunction is one of the most common eye problems. It develops from disease or dysfunction of one or more components of the Lacrimal Functional Unit that results in an unstable tear film that can cause eye irritation or pain, blurred and fluctuating vision, increased blink rate and ocular surface epithelial disease. The Dry Eye Workshop II has classified these conditions into aqueous deficient and evaporative; however, increased tear evaporation has been measured in aqueous deficiency, there are no clinical methods to measure tear evaporation and some tear dysfunction conditions have a normal or increased tear volume. A more practical method for diagnostic classification is to stratify conditions into those with a reduced or normal/elevated tear volume. This lecture will present a clinically practical approach to diagnose and classify tear dysfunction based on tear volume and review the essential components to identify and stratify tear dysfunction for targeted therapy.


Ocular Surface Tumors - To Biopsy or Not?
H. Peggy Chang

Ocular surface lesions range from the benign to malignant, with ocular surface squamous neoplasia (OSSN), conjunctival melanoma, and conjunctival lymphoma representing the three most common malignant tumors.  Definitive diagnosis is achieved with biopsy (ideally excisional with 3-4 mm margins and adjunctive cryotherapy in the case of OSSN or melanoma).  However, risks of surgery include pain, infection, and scarring that can lead to chronic irritation and unsightly redness.  The purpose of this presentation is thus to compare and contrast features of lesions that should undergo extensive surgery versus those for which one might pursue a more conservative treatment plan, such as close observation or topical chemotherapy.


New options for therapy of tear dysfunction
Stephen Pflugfelder

Therapy of tear dysfunction continues to evolve and there are a number of new options, including artificial tears containing osmoprotectants and lipids, the immunomodulatory agent lifitigrast, a nasal neurostimulator, plasma rich in growth factors (PRGF), Meibomian gland thermoexpression, conjunctivochalasis excision and an increasing array of scleral contact lenses. Evidence based attributes, therapeutic outcomes and recommendations for positioning these therapies will be reviewed. 


Persistent Epithelial Defects and Neurotrophic Keratopathy
Pedram Hamrah

Persistent epithelial defects and neurotrophic keratopathy can occur due to both acquired and inherited disorders of the somatosensory nervous system and result in decreased vision. This lecture will review the pathogensis if neurotrophic keratopathy and provide and updated paradigm for accurate diagnosis of this disease. Current clinical and surgical management of neurotrophic keratopathy will further be reviewed.


Ocular Allergy - New Diagnostics and Management
JoAnn Chang

Allergic conjunctivitis is an ocular surface disease that is often ignored, under diagnosed and under treated.   Many ocular allergy sufferers have other concomitant ocular surface diseases, where symptoms and clinical findings often overlap. Newer diagnostics for ocular allergy can assist practitioners on identifying the underlying etiology and contributing conditions, and in such, guide proper treatment for their ocular surface issues.  


pm session Ethics and Risk Management

Practice Gaps:  Using feedback from NEOS members and discussion by the Program Committee, include topics that focus on patient needs, expectations and processes to imporve and enhance patient care.  There are also gaps in presentatins that related to the varying clnical settings of our meembers.  It has bee noted that discussions need to encompass the different practice settings of our membership.

NEOS PROGRAM OBJECTIVES:  The content and format of this educationsl activity has been specifically designed to fill the practice gaps in the audience's curent and potential scope of professional activities by:

1) Obtaning a better understanding of standard of care practices and best practices in varying clinical settings.
2) This program will focus on communicating with patients and expand on patient care processes in academic, hospital and private practice settings to improve quality of care.
 


Cataract Surgery Practice Variations What Works Best for the Surgeon and the Patient
Christopher J. Soares

This discussion will review the various surgical approaches to cataract surgery and vet the scientific literature on what approaches are in the best interest of patients for safety and outcomes.  


Providing Quality Patient Care in Hospitals and Ambulatory Surgical Centers
Jill A. Smith

Ophthalmologists are fortunate to perform many surgeries which for the most part are well tolerated by their patients, have a low incidence of complications, and have successful surgical outcomes. Through the years there have been changing trends in the locations where the majority of ophthalmic surgeries are being performed, type of anesthesia being administered, and surgical techniques being used. We will look at these trends and review the data available to assess the strengths and the concerns in quality management regarding ophthalmic surgery in our effort to provide quality eye care for all of our patients.


OMIC’s Top Cataract Claims
George Williams

Complications and adverse events related to cataract surgery constitute the most common cause of medical liability claims. The high visual expectations, high volume and trivialization of cataract surgery contribute to many claims. This presentation will review representative closed cases with an emphasis on what went wrong, why it went wrong and how similar cases may be avoided.


THE UNIVERSE OF THE EXPERT MEDICAL WITNESS
Salvatore J. Loporchio

Salvatore J. Loporchio, MD, MPH, JD

Warren Alpert Medical School at Brown University

Providence, RI

:

Who is the expert medical witness?

What is their role?

When do they become recognized as an expert?

Where does this process take place?

Why do they enjoy such privileged status?

You are the named defendant in a medical malpractice suit.  The court room is filled.  The trial has begun.  Testimony will be taken from the plaintive and you, the defendant physician.  At some point in the proceedings, the expert medical witness - someone who has never met you or the patient will enter and offer their opinion as to whether or not the standard of care was met.  The plaintiff will likewise engage the services of an expert medical witness and the Judge and Jury will listen intently on their opinions and explanations to support their position.

Case law from the US Supreme court will be discussed and the court’s influence on medical malpractice litigation will be examined as well as the interplay of Congressional intent as provided for in the Rules of Civil Procedure and Federal Rules of Evidence.

Finally, the important distinction between a material witness and an expert medical witness will likewise be discussed.


B.Thomas Hutchinson, MD, Lecture: Retinal Malpractice; The OMIC Experience
George Williams

Medical liability claims related to the diagnosis and treatment of retinal disease are typically associated with profound or complete visual loss. This presentation will discuss closed OMIC claims involving retinal disease with an emphasis on the role of the patient in diagnostic errors, retinopathy of prematurity, posterior vitreous detachment, intravitreal injections and wrong events. Risk management programs and policies specific to retinal disease will be reviewed.


FLACS, ISHF, and CXL: Informed Consent in the Evolving Landscape of Anterior Segment Surgery
Naveen Rao

In recent years we have seen numerous advances in anterior segment surgery. As many new devices and techniques gain traction in the US, it is becoming increasingly difficult to ensure that our patients are adequately informed about risks, benefits, and alternatives of each treatment option. It can be challenging to explain key points without overwhelming patients with too much information. In this talk we will explore nuances of informed consent as it relates to femtosecond laser-assisted cataract surgery, intrascleral haptic fixation of intraocular lenses, and corneal crosslinking. Topics will include:

  • What does it mean to be truly informed?
  • How to consent patients: on paper, on video, by proxy, or in-person?
  • Using sutures, intraocular lenses, antibiotics, and crosslinking for off-label indications - what do patients need to know?


Issues in Informed Consent
George Williams

Informed consent is the most effective tool in risk management. Proper informed consent is the foundation for defense of virtually every medical liability claim. It is critical to recognize that informed consent is not a signature on a form, but a dynamic process of interchange between the patient and physician. This presentation on informed consent will discuss the importance of documentation, disclosure of off label therapies and procedure specific consent.


Streamlining Pre- and Peri-Operative Processes for Cataract Surgery
Susannah G. Rowe

Pre-operative preparation for cataract surgery has evolved since the days of hospital admissions for intensive pre-operative systemic work-ups. Optimization of patients’ health status prior to surgery is no longer strictly required, and the standard of care for low-risk cataract surgery no longer dictates routine pre-operative systemic tests. In fact, extensive systemic evaluations prior to cataract surgery may create unintended barriers to care, as well as add unnecessary costs, without clear benefits in terms of patient safety or quality of care.

I will discuss current approaches to streamlining pre-operative evaluations for cataract surgery, including simplifying systemic health clearances; anesthesia evaluations; NPO guidelines, and diabetes management in the context of local, state and national standards, and in light of evidence regarding safety and quality of care. Implications for other ophthalmologic surgical procedures will be discussed. Finally, I will share results and lessons learned at Boston Medical Center after moving to telephone-based pre-operative clearances, and will review other on-going initiatives to simplify pre-operative processes for surgery patients and their providers.