April 20, 2018 Conference
PM - Emerging and Re-emerging Infections
Professional Practice Gaps: Feedback from NEOS members and Program committee review identified 1. Understanding the role of PCR in diagnosis of infectious diseases in the eye clinic. 2. Understanding optimal algorithms for diagnosis and treatment of common ocular diseases including corneal ulcers and herpetic eye disease at non-tertiary referral centers. 3. Understanding the best current management for endophthalmitis and toxoplasmosis chorioretinitis.
PROGRAM OBJECTIVES: 1.To identify the role of newer technologies, including PCR, for diagnosis of ocular infections. 2. To describe current approaches to diagnosis and treatment of corneal ulcers and herpetic eye disease. 3. To identify the optimal treatment regimens for endogenous endophthalmitis, toxoplasmosis chorioretinitis and syphilitic uveitis.
C. Stephen Foster
Keratitis secondary to herpes simplex or to herpes zoster virus is, generally, not difficult to diagnose because of the clinical features of each, whereas uveitis secondary to either of these members of the herpes family can be very difficult to diagnose, with delayed diagnosis very common. Additionally, HSV in particular may cause other forms of ocular inflammation, including recurrent conjunctivitis, episcleritis, or scleritis, which can elude diagnosis because of the lack of identifying clinical features and because of the rarity of such manifestations of HSV infection. Suggestions for a path to diagnosis for each of these matters, along with treatment recommendations will be presented
In this talk, an infectious disease physician's approach to answering the following questions will be discussed:
1. Patient with uveitis and a positive PPD -- could this be ocular TB?
2. Patient with uveitis and history of tick exposure -- could this be ocular Lyme disease?
3. Patient with acute retinal necrosis worsening on intravenous acyclovir -- what else can be done to save vision?
Infectious keratitis is a sight-threatening condition with potentially significant morbidity and economic impact in the United States. A CDC report from 2010 stated that pisodes of keratitis and contact lens disorders cost an estimated $175 million in direct health care expenditures and occupied over 250,000 hours of clinician time annually. The gold standard for diagnosis is culture of the causative organism, but imaging techniques and PCR sequencing may be useful. Topical antimicrobial therapy should be tailored to the microbial etiology (bacterial, fungal, amoebal, or viral), but managing the host inflammatory response is crucial to prevent poor outcomes such as corneal melting, scarring, and perforation. Newer therapies such as corneal collagen crosslinking and photodynamic therapy are promising.
Despite of the recent progresses in the area of molecular diagnosis, laboratory identification of organisms causing eye infections is widely performed by old-fashioned and time-consuming techniques, such as microscopy and culture. Because of the diminutive size of eye specimens, and the fact that many ocular pathogens cannot be readily cultured, after several days of effort, a report is often returned as negative, despite clear clinical evidence of an infection. Patients are thus started on broad-spectrum therapies with one or two antimicrobial agents, and de-escalation to a targeted therapy based on the laboratory results may take days or weeks. In the interim, the infection continues its destructive path, much of it preventable if the pathogen was quickly known. New technologies have the potential to quickly diagnose the microbe causing an infection, as well as its antibiotic resistance, providing the physician with critical information in hours, rather than days. In addition, because of the enhanced sensitivity of these methods, a positive test is reported to a greater number of patients. This presentation will explore the advantages of the newest cutting-edge technologies (e.g. digital counting of barcoded DNA and next generation sequencing) for detection and identification of nucleic acids to develop rapid, sensitive and comprehensive diagnostic tests for eye infections.
David Hinkle, MD
Audina Berrocal, Camila Ventura
We will do a historical review of the Zika virus and understand how it came to the New World. Furthermore, we will have an update of the Zika virus and the syndrome in the United States and Latin America in 2018.
Syphilis, an ancient disease, first noted in the 1400’s, has unfortunately been making a comeback all across the world, with reports of increased activity in every nation. Rates in 2015 were the highest on record, with the CDC reporting nearly an 18% rise in documented cases of syphilis. Reasons for this alarming statistic vary from unprotected sexual activity, particularly in men having sex with men to new HIV-preventing medications which decrease the stigma associated with condom-free sex, to online dating apps.
Traditionally, practitioners have tested for syphilis with non-specific treponemal tests such as RPR and VDRL. However, these tests may give a false sense of security as they may not turn positive in acute disease. Specific treponemal tests such as Treponema pallidum antibody or fluorescent treponemal antibody absorbed (FTA-Abs) should be checked to avoid missing this important diagnosis.
The ocular presentation of syphilis can vary from scleritis to panuveitis and thus it is prudent to include testing for syphilis for those uveitis patients who warrant a systemic uveitis evaluation, regardless of age, gender, or reported risk factors.
Audina Berrocal, Camila Ventura
Infectious diseases in the neonate are uncommon but may be devastating. We will review the most common infectious diseases and the clinical signs and symptoms of their presentation. Not only will we look at the most common but also we will discuss the ZIKA virus and give and update on the syndrome.
To review the presentation, pathophysiology, diagnosis, and management of endogenous endophthalmitis in the setting of our regional and national opiod crisis with increased rates of IV drug use.
Purpose: From 2000 to 2014, the United States experienced a tripling in number of opioid overdose deaths. As of 2015, New Hampshire has one of the highest age-adjusted rates of death due to drug overdose at 34.3 per 100,000 persons. We investigated clinical characteristics of injection drug use (IDU) versus non-IDU endogenous endophthalmitis (EE) at Dartmouth-Hitchcock Medical Center (DHMC) during the opioid epidemic.
Methods: A retrospective chart review identified EE cases from January 2012 to December 2016 at DHMC via International Classification of Diseases (ICD-9, ICD-10) codes 360.0*, 360.1*, H44.0*, and H44.1*. Patient demographics, IDU history, microbial data, and clinical courses were recorded and analyzed.
Results: Fifteen patients with EE were identified, of which 9/15 (56.3%) had a history of IDU. Reduced vision was the most common presenting symptom in all IDU (9/9) and most non-IDU (5/6) patients. Compared with non-IDU patients, IDU patients were younger (31 vs 63 years, P<0.001) and had fewer co-morbidities. There was a trend for IDU patients to delay seeking care compared with non-IDU patients (24.7 vs 2.0 days). IDU patients demonstrated significantly more improvement in visual acuity after intervention than non-IDU patients. Non-IDU cases were more likely to present during hospitalization or shortly after discharge and less likely to undergo surgical intervention because of more frequent resolution of vitritis.
Conclusions: Patients with IDU-related EE were younger, ambulatory, and presented later than non-IDU related EE patients. Importantly, IDUrelated EE patients were more likely to experience improved vision with treatment than non-IDU related EE patients. IDU patients represent a younger and healthier subset of the EE population and may regain vision upon prompt recognition and treatment.
1. Tirpack AR, Duker JS, Baumal CR. An Outbreak of Endogenous Fungal Endophthalmitis Among Intravenous Drug Abusers in New England. JAMA Ophthalmol. 2017 Jun 1;135(6):534-540. 2. Bobeck S. Modjtahedi, MD, Avni V. Finn, MD, Thanos D. Papakostas, MD, Marlene Durand, MD, Deeba Husain, MD, Dean Eliott. Intravenous Drug Use–Associated Endophthalmitis. Ophthalmol Retina. 3. Patel SN, Rescigno RJ, Zarbin MA, Langer P, Bhagat N. Endogenous endophthalmitis associated with intravenous drug abuse. Retina. 2014;34(7):1460e1465.
AM - Glaucoma Improving Outcomes in Glaucoma Treatment, Choices, Choices!
Practice Gaps: Using feedback from NEOS members and discussion by the Program Committee, we have identified the broad topic of how to choose evolving old and new choices in glaucoma treatment to improve outcome as professional practice gaps in our membership. The practice gaps include specifically, how to choose from different glaucoma eye drops, new glaucoma drug delivery systems, glaucoma medication adherence techniques, new surgical modalities such as MIGS, Micropulse Cyclophotocoagulation laser therapy, Femto Laser Assisted Cataract Surgery in glaucoma patients, and old and new choices in wound healing modulators in glaucoma surgery.
Objectives: The content and format of this education activity has been specifically designed to fill the practice gaps in the audience’s current and potential scope of profession activities by:
- Increasing the attendees’ competence in understanding the various old and new choices in medical, laser and surgical treatment of glaucoma.
- Improving attendees’ performance in choosing and incorporating new modalities of glaucoma treatment into their daily practice.
- Improving attendees’ outcomes in utilizing the most appropriate treatment option in terms of safety and efficaciousness.
Pharmacologic therapy is a mainstay of glaucoma treatment. Prostaglandin analogs have excellent ocular hypotensive properties, have very rare instances of systemic side effects, and offer once daily dosing schedules that could increase compliance. However, they can have cosmetic side effects that may be undesirable in cases of monocular therapy. Beta-blockers are effective and safe, but cardiopulmonary side effects can be a concern for some patient populations. Carbonic anhydrase inhibitors also lower intraocular pressure, but must be dosed twice daily, and have an unfavorable pH which can limit compliance in sensitive patients. Alpha adrenergic agents are also effective, but produce a high rate of allergy. Combination agents (Cosopt, Combigan, Simbrinza) can increase compliance and decrease the preservative load on the eye.
Objective: The objective of this presentation is to demonstrate to the audience the methods to improve glaucoma medication adherence?
Abstract: Glaucoma is a degenerative and progressive optic neuropathy that results in irreversible vision loss. Currently, the mainstay of treatment is medication with laser treatment and surgery available when medication treatment is not sufficient or viable option. Unfortunately studies have shown that adherence to glaucoma medication can be highly variable—ranging from as low as 30% to as high as 75%. Poor adherence can lead to glaucoma progression and poor outcomes. Recent estimates reveal that glaucoma affects approximately 5% of the population over 65 years of age and 10% of the population over 75 years of age. The elderly population is expected to double in the coming decades and along with the aging population so will the number of people with glaucoma. The problem of non-adherence is only going to be compounded by the higher prevalence of glaucoma in the coming years and will place an ever increasing burden on ophthalmic care not only in terms of cost but also access. Hence, the problem continues to need solutions and challenges physicians daily. There are a number of steps that physicians can consider to improve compliance with medication including better communication, family support, education, technology, patient support groups, and cost cutting measures. One method or a combination of methods may ultimately help a particular patient. This talk will review methods that physicians can consider and use to engage their patients to help individuals improve medication compliance.
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Leske MC, Heijl A, Hussein M, et al. Factors for glaucoma progression and the effect of treatment: the early manifest glaucoma trial. Arch Ophthalmol. 2003;121(1):48–56.
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Boland MV, Chang DS, Frazier T, Plyler R, Jefferys JL, Friedman DS. Automated telecommunication-based reminders and adherence with once-daily glaucoma medication dosing: the automated dosing reminder study. JAMA Ophthalmol. 2014 Jul; 132(7):845-50.
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Financial Disclosure: None.
Non-adherence to medical treatment for glaucoma is notoriously prevalent and is linked to progression of the disease. Among the barriers to adherence are difficulty with eye drop administration, side effects, forgetfulness, perceived life stress, and cost. Numerous novel drug delivery systems for glaucoma are currently being developed and seek to remove several of these barriers by taking the task of medication adminsitration out of the hands of patients. A comprehensive overview of the past, present, and future of sustained drug delivery for glaucoma and its perceived benefits will be presented.
M. Lisa McHam
Traditional Diode laser transcleral cyclophotocoagulation (TSCPC) is a commonly used procedure for lowering IOP in patients with difficult to treat glaucoma. It works by damaging the ciliary body, which decreases aqueous production. Typical patients have had previous glaucoma surgeries and have limited visual potential. Although effective, the extensive tissue destruction can lead to complications such as prolonged inflammation, hypotony, and vision loss. The development of Micropulse Diode CPC is an attempt to harness the IOP lowering benefits of the traditional procedure while reducing risks and potentially broadening the clinical applications. I will review the current experience with Micropulse CPC, including results, patient selection, and evolving techniques.
The managmenent of coincident cataract and glaucoma ranges from phacoemulsification alone to phacoemulsification combined a wide ranging variety of glaucoma procedures including canal surgery, supraciliary surgery, and transcleral surgery. Each option presents a unique risk benefit profile. This discussion will review some of the decision making processes involved to individualize the surgical management of glaucoma.
The femtosecond laser can be used to perform several steps of cataract surgery. This technology presents unique challenges and opportunities in patients with coexisting glaucoma and related conditions. Advantages include precise and atraumatic capsulotomies in eyes with intumescent cataracts, shallow anterior chambers, or zonular weakness with or without lens subluxation. Laser nuclear fragmentation reduces effective phacoemulsification time and endothelial cell loss, a potential benefit in eyes with dense cataracts or endothelial compromise. Glaucoma procedures including MIGS, trabeculectomy or tube shunts can be combined with laser-assisted cataract surgery with only minor changes in technique. Potential challenges include applanating the ocular surface with the laser interface in eyes with severe periorbital fat atrophy. High limbal blebs or patch grafts can also interfere with the docking procedure. The laser capsulotomy size can be changed in eyes with poor dilation but mechanical pupil dilation requires additional modifications. IOP rise is transient, but caution is advised in patients with advanced field loss.
NEOS meeting 4/20/18
Talk: Old and New Choices of Wound Healing Modulators in Glaucoma Surgery
1. Wound healing brief review: Coagulative, inflammatory, proliferative, remodeling
Wound healing modulation
2. Brief review of MMC and 5FU
3. Newer agents
1. Collagen matrix Ologen
2. anti VEGF injections
3. Amniotic membrane
4. Novel agents
1. Anti-Placental growth factor
7. Transforming Growth Factor Beta
Is it better to mitigate disease risk or surgical risk? It cuts both ways. Treating the disease aggressively, with hightly efficacious surgical management will mitigate disease risk as a low IOP is often achieved. Yet, in doing so, the patient is subjected to signficant surgical risk. Conversely, a much safer, less efficacious procedure lessens surgical risk, but may not adequately lower IOP, thus subjecting the patient to increase disease risk.
The traditional offerings for surgical management of glaucoma such as trabeculectomy and tube shunts have considerable risk, at times far exceeding disease risk. The era of perfoming trabeculectomy for those at lower risk for true function impairment from glaucoma are waning. The contemporary glaucoma surgeon offers a portofio of procedures, each with a unqiue risk benefit profile that may be matched to the disease risk faced by individual patients. Level of IOP control, target IOP, likelihood of progression, life expectancy, coagulation status, compliance and tolerance of medications, status of the native lens, availablility for postoperative care, status of the fellow eye, and prior surgical history are all variables that should be considered when selecting a procedure for each unique patient. This discussion will address decision making in glaucoma surgery.
“Surely intelligence wasn‘t enough; moral clarity was needed as well. Somehow, I had to believe, I would gain not only knowledge but wisdom, too.” Paul Kalanithi, M.D. “When Breath Becomes Air” (1)