March 9, 2018 Conference
PM Session: Innovations in Ophthalmology
Professional Practice Gaps: Feedback from NEOS members and program committee review identified limited knowledge of the latest advances in ophthalmic gene therapy, treatment of proliferative vitreoretinopathy, screening and management of amblyopia, K-pro, surgical glaucoma, advances in refractive treatments, OCT imaging analysis and retinoprosthesis.
Program Objectives: 1. Improve awareness of emerging and evolving technologies and techniques in ophthalmology as outlined above.
2. Improve ability to counsel patients regarding important new technologies and techniques in the management of PVR, glaucoma, amblyopia, refractive error/presbyopia and inherited retinal degenerations.
Invented by Claes H. Dohlman, MD PhD, and first approved for marketing by the FDA in 1992, the Boston keratoprosthesis design has been in near continuous evolution since its inception. As the most widely used keratoprosthesis in the world with over 13,000 devices implanted to date, implantation of a Boston keratoprosthesis is indicated for corneal blindness in patients with good visual potential who have previously failed or are very likely to fail traditional corneal allograft surgery. This presentation will focus on current and future design innovations conceived to increase safety and reduce costs associated with implantation of the device.
Dean Eliott, Tommy Stryjewski, Leo Kim
PURPOSE: Methotrexate is an antiproliferative and anti-inflammatory agent with minimal ocular and systemic toxicity, and it is a good candidate to study for the prevention of proliferative vitreoretinopathy (PVR). The purpose of this study was to attempt to prevent recurrent retinal detachment (RD) due to PVR in a series of high risk eyes.
METHODS: We conducted a prospective study of 10 eyes with RD due to PVR. Eight of these eyes had undergone multiple procedures for recurrent RD and two eyes had RD after primary repair of severe open globe injury. All 10 eyes underwent surgery which included retinectomy and silicone oil. A total of 10 intravitreal injections of methotrexate (400 mcg/0.1 ml) were administered per patient: one at the conclusion of surgery, eight weekly injections from postoperative week 1 through week 8, and one additional injection at postoperative week 12. Outcomes included recurrent RD and PVR. We then treated an additional 16 eyes with 13 injections each.
In addition, fibrous proliferations excised at the time of PVR surgery were grown in culture. The cells were exposed to varying concentrations of methotrexate.
RESULTS: There was 99% compliance, as 99 out of a possible 100 total injections were given. All patients had 3-4 years of follow-up except for one patient who had only 4 months. One trauma patient developed severe PVR at month 4 (one month after the last injection), which is much later than expected. Three eyes developed RD without any observable evidence of PVR. Only one eye developed an observable epiretinal membrane and it was clinically insignificant. For the additional 16 eyes, only 1 eye developed recurrent RD due to PVR.
Cultured human PVR cells exhibited uncontrolled proliferation and extracellular band formation. Methotrexate exposure resulted in decreased cell proliferation and decreased band formation in a dose response manner.
CONCLUSIONS: The use of multiple intravitreal methotrexate injections is a reasonable approach for the prevention of PVR. This small prospective study with long term follow-up demonstrates safety and tolerability, and there is a suggestion of efficacy in this cohort and in the additional 16 eyes. In addition, there is some confirmatory laboratory evidence using cultured human PVR cells. There is enough favorable evidence that this approach warrants further study.
David G. Hunter
Although amblyopia can be treated effectively at a young age, it remains the leading cause of monocular vision loss in children due to (1) delays in detection and (2) poor compliance with prescribed treatment. In this presentation we will discuss new approaches to amblyopia screening and its treatment. For screening, a method known as retinal polarization scanning has been significantly more accurate than existing approaches for detection of amblyopia and strabismus. For treatment, new approaches focusing on binocular therapy have the promise of better compliance with treatment, while both binocular therapy and prolonged dark exposure may reawaken the brain's plasticity and enhance treatment even in older patients. The successes and ongoing challenges of these innovations will be discussed.
PURPOSE: To highlight the new technology and future trends in refractive surgery introduced by lenticular extraction (SMILE).
METHODS: Small incision lenticular extraction (SMILE) is a new generation form of laser vision correction that has been growing in popularity outside the U.S. over the past 9-10 years, and is now experiencing early U.S. adoption since its FDA approval 1 year ago. The technique involves a femtosecond laser created posterior lenticular shaped interface and anterior uniform thickness cap with a small external incision through which the refractive lenticule is extracted. The greater preservation of the ocular surface, anterior corneal fibers, and corneal nerves make it less invasive than LASIK. However, the steps of longer laser delivery, dissection and extraction make it more technically challenging than LASIK. With the laser assisted extraction of lenticules comes the possibility of lenticular implantation in the future.
RESULTS: SMILE has grown to greater than 1 million procedures world-wide this past year with over 500,000 Chinese procedures being performed in 2017 alone. In many OUS locations, SMILE has become the dominant refractive procedure being 80+% of cases in Shanghai and South Africa and 60% in Sydney, Australia. SMILE’s growth in the U.S. is more tempered, due to only spherical myopic approval, but astigmatism approval is forthcoming within the next year. SMILE is believe to be superior to LASIK in its avoidance of flap related complications, less potential dry eyes, less biomechanical instability, closed system precision and the momentum of a new procedure without the historical limitations of LASIK. The potential for intraoperative complications can be minimized by redocking in the case of suction loss, careful dissection of the anterior and then posterior interface, and inspection of the extracted lenticule to avoid partial removal. So far, the potential for lenticular implantation has been proposed for the correction of hyperopia, presbyopia and keratoconus.
CONCLUSION: SMILE has the potential to strongly co-exist and even replace LASIK as the dominant procedure in refractive surgery. With refractive eyebanking of extracted lenticules, a new era of tissue addition in refractive surgery could revolutionize the way we correct certain refractive errors.
The recent FDA approval of gene augmentation therapy for RPE65-associated retinal degeneration suggests that gene and genetically directed therapies have great potential for the treatment of inherited eye disorders, such as inherited retinal degenerations (IRDs). The different therapeutic approaches currently being studied for the treatment of IRDs will be discussed. The status clinical trials of gene and genetic therapies for IRDs will be reviewed.
Peter Chang, C Stephen Foster, Razzaque Ahmed
Six OCP patients, 4 of whom were monocular at baseline, received RTX and IVIg infusion in a particular regimen: RTX is given at 375mg/m2 BSA weekly for 8 weeks, followed by 4 monthly infusions; IVIg at the dose of 2g/kg divided over a 3-day cycle is given immediately before the institution of RTX therapy, then given monthly for a total of 6 months, then stretched to every 6, 8, 10, 12, 14, and 16 weeks. The total follow-up after the completion of the combination therapy is 104 months (8.7 years), and all 6 patients had no progression in OCP staging and maintained baseline BCVA. No infection or death was associated with the combination therapy. B-cell data and levels of auto-antibodies to human beta-4 integrin, the latter of which correlated with OCP disease activity, will be provided in this presentation.
Emerging Novel Automatic Image Analysis to Allow Early Detection of Systemic Diseases based upon OCT and OCTA Imaging
Department of Ophthalmology and Visual Sciences
University of Massachusetts Medical School. Worcester, MA
To develop and employ a novel mathematical software algorithm that enables the automatic detection of early microvasculature changes in the retina and to correlate these automatically detected changes with the presence of systemic diseases.
This is an ongoing a prospective, observational study that includes more than 500 patients with systemic diseases (sleep apnea, diabetes, hypertension, and pre-eclampsia) and age matched controls. Optical coherence tomography angiography (OCTA) was performed using Cirrus HD-OCT 5000 Angioplex (Carl Zeiss Meditech, CA. USA). Patients underwent 3x3mm and 6x6mm macular scans that were captured at ~840nm wavelength and 68,000 A-scans/second and the split-spectrum amplitude-decorrelation angiography algorithm was utilized. An automatic mathematical analysis software was developed to automatically detect retinal microvasculature on OCT and on OCTA images, including superficial and deep retinal cuts. The developed software consisted of three main stages: firstly reduce the noise and improve the contrast by using the GGMRF model, secondly retinal segmentation was performed by integrating current and prior intensity models, and a higher-order spatial MGFR model. Finally, total retinal microvasculature analysis was performed by applying connectivity analysis to present more accurate results.
The automatic OCT and OCTA analysis software detected early development of micro-vascular changes that were not apparent by other investigation modalities as well as areas of capillary loss. Alterations in vascular structure were noted as well as increased vessel and capillary tortuosity. Enlargement of the foveal avascular zone (FAZ) appeared to be one of the earliest changes in diabetic patients. The automatic software was able to accurately detect areas of non-perfusion and decreased vessel density. Automatic detection of early microvasculature pathology carries the promise of early detection of systemic diseases to allow prevention of progression towards more advanced retinopathy.
Ronald Krueger, Vinicius Silbiger De Stefano
Purpose: Since the U.S. approval of topography-guided customized treatments (TCAT), much debate has ensued regarding the appropriate planning strategies when manifest and topographically measured cylinder values differ in axis and magnitude. We wish to analyze our pattern of success among the eyes that gained one or more lines of best corrected visual acuity (BCVA).
Methods: 256 eyes undergoing TCAT by a single surgeon from Feb 2016 to May 2017 were enrolled in this retrospective study at the Cleveland Clinic. All eyes were healthy, and had at least 4 good quality topographic maps. The corneal shape was captured with the Topolyzer, and coupled with the eye’s refraction to generate an ablation profile with the Allegretto Wave Eye-Q laser. The cylinder magnitude and axis of laser entry were decided by the surgeon, based on both the manifest and measured values, assisted by additional data from a tomographer (Pentacam) and ocular wavefront (LADARWave). All patients were followed at 1 day, 1 week and 3 months.
Results: At three months, 95.7% achieved UDVA of 20/20 or better, while 81.4% were 20/15 or better. 25.6% gained one or more lines of BCVA. Among these eyes, measured and manifest axis differed by less than 15° in 59%, between 15° and 30° in 18% and more than 30° in 23%. When it differed by at least 5°, the measured axis was treated in 79%, 67% and 73% of eyes, respectively. In the 68% of eyes with greater measured cylinder magnitude, 75% were treated between manifest and measured with only 7% at full measured value (TMR). By contrast, when manifest was greater, 60% were treated at total measured value and 40% in between. Despite the improvement in vision, whole-eye aberrometry showed a significant increase in coma, spherical aberration and total RMS (all p < 0.001).
Conclusion: TCAT can achieve better than glasses vision in more than a quarter of eyes. In eyes gaining a line of vision, the measured axis is treated in ~75%. When the measured magnitude is higher, a value between the measured and manifest is chosen in 75% to avoid overcorrection. Tomography and ocular wavefront values assist in the selection process.
AM - Retina: Posterior Segment Surgery/Complications in Relation to Anterior Segment Surgery
Educational Gaps:Feedback from NEOS members and program committee review identified current trends in posterior segments complications related to anterior segment surgery as a practice gap.
Program Objectives: The content and format of this educational activity has been specifically desigend to fill the practice gpas in the audience's current and potential scope of profession activities by:
1. Improving outcomes in the area of complications related to anterior segment surgery.
2. Improving the performance of the audience in placement of intraocular lenses.
3. Increasing the competence of the audience in the aras of recognition of infections related to intraocular surgery.
Endophthalmitis is bacterial or fungal infection within the eye, including involvement of the vitreous and/or aqueous humors. Endophthalmitis may develop via exogenous or endogenous (hematogenous) routes, with different microbiology depending on the mechanism of infection. Post-operative endophthalmitis can occur following various ocular procedures, most commonly cataract surgery. This talk will highlight new literature on postoperative endophthalmitis, which focuses on updating understanding of the microbiology, approaches to prevention including intracameral and systemic antibiotics and intraoperative iodine irrigation, and treatment, particularly in regard to the rising concern about hemorrhagic occlusive retinal vasculitis (HORV) following intraocular vancomycin injections.
Intraocular vancomycin has been associated with a rare but sight-threatening condition that has been termed hemorrhagic occlusive retinal vasculitis (HORV). It is thought to be a delayed hypersensitivity reaction, and occurs after an otherwise uneventful intraocular procedure that involved intraocular vancomycin. Characteristic clinical findings of HORV include unremarkable postoperative day 1 undilated examination, delayed-onset painless vision loss, mild anterior chamber and vitreous inflammation, sectoral retinal hemorrhages in areas of ischemia, and predilection for venules and peripheral involvement. Early treatment with corticosteroids is likely beneficial. Subsequently, anti-vascular endothelial growth factor injections and panretinal photocoagulation are important to prevent neovascular glaucoma, a common complication. Avoidance of additional intravitreal vancomycin is recommended if HORV is suspected.
Jeffrey K. Moore
Macular disease from diabetes and macular degeneration affect more than 1 in 20 patients aged 40 or older undergoing cataract surgery. Meeting the high demands of cataract surgery today requires an understanding of when retinal disease may affect cataract surgery results and when cataract surgery may lead to a progression of retinal disease. The purpose of this talk will be to review macular findings in diabetic retinopathy and macular degeneration which may influence outcomes or be at risk of disease progression in the setting of cataract surgery. Risk directed perioperative evaluation and counseling will be reviewed as well as recommendations to guide coordination of surgery in patients actively under treatment for macular disease.
The advent of Anti-VEGF medications has revolutionized the management of wet age related macular degeneration (AMD). Instead of losing vision, most patients maintain and in some cases improve vision. But despite these advances, current therapy requires frequent injections and does not cause CNV regression. The angiogenesis cascade is complex and VEGF is only one part. There are numerous other cytokines involved in the process and using these other pathways either alone or in combination with ant-=VEGF may improve outcomes in this common blinding disease.
Dislocated PCIOL’s is a unfortunate complication of cataract surgery. Using appropriate management techniques the surgical and visual outcomes can be excellent. Not all techniques are necessary for any given case; however, certain principles favor one technique over another. Worst case scenario, removal of the lens with placement of an ACIOL is always a possibility with good visual outcomes. In this lecture, we will look at best practices for cataract surgeons when faced with a complicated cataract surgery, and tips and tricks for retina specialists in how to approach these surgical problems.
YAG Vitreolysis for Symptomatic Floaters
Chirag P. Shah, MD, MPH
NEOS March 2018
About two-thirds of patients older than 65 years have a posterior vitreous detachment; many are bothered by their floaters. Ophthalmologists often inform patients they will neuro-adapt to the floaters with time, which is often true. But some patients have residual symptoms that can significantly affect their quality of vision and thus their quality of life.
There are only two known treatment options for floaters: vitrectomy and YAG vitreolysis. Small gauge vitrectomy systems may have lowered our threshold to offer vitrectomy for floaters, but there are inherent risks to vitrectomy. Everyone gets a cataract. Studies have reported rates of retinal detachment to be as high as 10.9% . Further, there is a small risk of infection, as well as the inherent risks of anesthesia.
YAG vitreolysis may serve as a middle-ground treatment option for floaters between observation and vitrectomy. However, the evolution of YAG vitreolysis has contributed to its controversy; providers have performed the procedure for years without sufficient clinical trial data.
Recently, a pilot study randomized 52 patients to YAG vitreolysis versus sham laser, reporting a moderate improvement in floater symptoms with no significant adverse events . YAG treated patients reported a 54% improvement in their symptoms compared to a 9% improvement in sham treated patients after a single treatment session. The VFQ-25 showed improved general vision and peripheral vision, with less role difficulties and dependency among the YAG laser group. Objectively, a masked grader found that the floater appearance was significantly or completely improved in 94% of YAG treated eyes on wide-field color photography.
The field of YAG vitreolysis is still in its infancy, with more studies needed to better understand its efficacy and safety, as well as to better identify which floater-types and patient-types are best suited for this procedure. Indeed, further randomized controlled trials are underway in Japan, Germany, and France. At present, glaucoma, cataract, retinal damage, and retinal detachment are all known risks of YAG vitreolysis, but we need large studies with long follow-up to determine the rates of these risks. We should have more clinical trial data about YAG vitreolysis in the next few years.
Use of laser vitreolysis for symptomatic floaters has increased in recent years, but prospective studies are not available to determine the efficacy of this procedure, and the complication profile of this intervention is poorly understood. In 2017 a retrospective assessment was performed of all cases of complications following laser vitreolysis that were voluntarily reported by practitioners throughout the United States to the ASRS ReST Committee. Complications included elevated intraocular pressure leading to glaucoma; cataracts, including posterior capsule defects requiring cataract surgery; retinal tear; retinal detachment; retinal hemorrhages; scotomas; and an increased number of floaters. Although the rate of complications cannot be determined because the denominator of total cases is unknown, these serious sight threatening complications merit the performance of prospective studies to better understand the efficacy of this procedure and the frequency of attendant complications. Until then, practitioners should be aware of the profile of potential complications to properly inform patients during the consent process.
This debate was given by Fina Barouch, MD.
Anterior chamber intraocular lenses (ACIOLs) have improved greatly since early versions which often caused severe side effects. Newer versions are better but still have risks of corneal damage, glaucoma, and inflammation and require a large corneal incision for implantation.
There are multiple options for fixating posterior chamber IOLs when there is not sufficient capsular support including iris-sutured, scleral-sutured, and scleral-fixated without sutures. These techniques continue to improve and can allow individualized surgery for each patient with excellent results. This talk will discuss all of these techniques with special focus on IOL optic and haptic composition, optic size, foldability, incision size, suture selection, and wound construction.
Fixated PCIOLs offer many advantages over ACIOLs and are often a better choice for the patient.
In 2018, ophthalmic surgeons rarely encounter situations of poor or absent capsular support in an eye that requires an IOL placement. While several options exist to make such eyes pseudophakic, the literature and common sense suggests that AC IOLs are the way to go.
Lucian Del Priore
There are two options for management of the crystalline lens during planned pars plana vitrectomy surgery for macular disease; namely, phacoemulsification combined with pars plana vitrectomy, versus separate cataract surgery performed before or after pars plana vitrectomy. The major advantages of the combined approach include one surgical procedure rather than two; faster visual rehabilitation, since a combined approach avoids a delay of 1-3 months between surgeries; decreased cost to the patient and the health care system; and theoretical lower risk of endophthalmitis related to breakdown of sterility in the surgical field. Additional considerations during the combined surgical approach include sequence and location of port placement; management of the corneal wound (sutures versus rehydration); and possible need for adjustment of IOL calculations in the presence of preoperative macular disease. When presented with the option, most patients will favor the combined approach as it eliminates the need for a second surgical procedure. All options need to be carefully weighed in counseling patients regarding choices around vitrectomy surgery.
Arguments and Evidence to support separating phaco/IOL and vitrectomy will be presented. Minimizing potential for surgical complications involves playing to our strengths and avoiding more surgery than is necessary in an effort to achieve the best results for our patients. KEEPING IT SIMPLE!
Combining cataract surgery with vitrectomy will at a minimum prolong surgery and invites the immediate potential for anterior segment problems including corneal edema and pupillary constriction or distortion or inflammation that may make an otherwise straight forward vitrectomy surgery much tougher and more traumatic and more complicated. Splitting the surgery into its component parts may preserve lens function for an extended period of time and sometimes indefinitely when the vitrectomy is done first or if cataract surgery is done first, may avoid vitrectomy altogether if the patients visual needs prove to be met by the cataract surgery alone.
Macular pucker induced distortion, thickening or edema has the potential to cause inaccuracies in IOL power determination. this could be alleviated by doing the pucker surgery first , allowing the macula to "defervesce" and then performing a more accurate calculation.
Cataract formation is probably the most common "complication" of vitrectomy surgery. Innovative approaches to certain macular surgeries can be done to moderate the cataractogenic nature of vitrectomy.
Certainly one can concede that there are instances where strong patient preference or cost may push one to do combined anterior and posterior segent surgery. In general more surgery equals longer OR times, more risk of complications and more inflammation. The KISS principle of surgery and life dictates we follow a staged approach as necessary in the setting of surgical vitreous pathology.