April 12, 2019 Conference
AM - Glaucoma Care from Patient to Population
Professional Practice Gaps: Feedback from NEOS members and Program committee review identified potential practice gaps including knowledge on the latest diagnostic and surgical advances in glaucoma as well as population- and practice-based topics, such as screening and how to best manage increasing numbers of glaucoma patients.
PROGRAM OBJECTIVES: The content and format of this educational activity has been specifically
designed to fill the practice gaps in the audience’s current potential scope of professional activities by:
- Increasing the awareness of and competence with some of the latest diagnostic and surgical advances in glaucoma.
- Improving knowledge regarding how best to screen for and efficiently care for the increasing glaucoma patient population.
Functional deficits in glaucoma can be assessed by visual field testing using either automated static perimetry, or less commonly kinetic Goldmann perimetry performed by a skilled perimetrist, or highly specialized electrophysiological techniques, such as the recording of retinal ganglion cell (RGC) response with the pattern reversal electroretinogram (PERG) and the photopic negative response (PhNR). Clinicians most commonly employ automated static perimetry to look for characteristic functional defects and then repeat these tests to assess for progression. However, visual field defects in glaucoma may not show up on automated field tests until 25% to 35% of the RGCs have been lost. Electrophysiological methods provide objective measures of retinal ganglion cell function that are more sensitive to glaucomatous damage making them ideal for earlier diagnosis and monitoring. However, these highly specialized clinical tests are less readily available and saturate early in the disease, making them less useful for monitoring advanced glaucoma.
Claudia U. Richter
The MIGS surgical options available to treat glaucoma with cataract surgery continue to evolve. The current options include trabecular stent (iStent Inject and Hydrus), Schlemm's canal unroofing (Trabectome, Kahook dual blade, goniotomy, trabeculotomy 360), and reduction of aqueous humor production (endoscopic laser cyclophotocoagulation, micropulse laser cyclophotocoagulation: The results with these procedures amd advantages and disadvantages sill be briefly reviewed. The early results with the iStent Inject will be presented.
The recent, dramatic increase in surgical options to treat glaucoma has created new opportunities, but at the same time it has made determining the best choice for individual patients more complex. Balancing the unique potential benefits and risks of each surgery to the unique needs and issues confronting each glaucoma patient is a challenging but critical task for clinicians. This lecutre will review considerations for each type of glaucoma surgery and how they relate to typical and atypical patient features and concerns, including IOP goals, risks for complications, refractive goals, and postoperative course.
After participating in this course, physicians will be able to (1) describe the benefits and risks of the full range of glaucoma surgeries available in the United States and (2) apply this knowledge to balance surgical features with patient issues, taking into account unique patient needs and goals.
The healthcare burden of glaucoma care is rapidly increasing. Year upon year, the incidence of new glaucoma cases is rising, in conjunction with increasing impacts of cataracts and macular degeneration. Across the United States, optometry has been permitted to treat glaucoma with topical anti-hypertensive medications, with the exception of Massachusetts. In addition, OK, KY, and LA allow optometrist to perform lasers. Inevitably, we are faced with the reality that glaucoma care will be comanaged. We need to be proactive and examine our relationships with community optometrists, and determine what approach will be in the best interests for our patients. Legislation is unlikely to provide a uniform approach for glaucoma comanagement, and we must take the initiative to define clearly the process by which we set the expectations for shared patient care.
Primary angle closure (PAC) encompasses a wide variety of conditions with different severity (narrow angles to severe glaucoma) and presentations (acute, subacute, and chronic). The evaluation of the anterior chamber (AC) angle is critical in diagnosis and treatment of PAC. Gonioscopy remains the gold standard diagnostic test, anterior segment OCT and ultrasound biomicroscopy (UBM) are also important diagnostic modalities in the evaluation of the AC angle. Laser peripheral iridotomy is the most common therapy for PAC. Due to the Eagle study and other studies, lens extraction with or without a glaucoma procedure (i.e. goniosynechiolysis, endocyclophotocoagulatio, or trabeculectomy) are becoming more popular and accepted for treatment of PAC.
In their seminal 1982 paper, “Why Do Some People Go Blind From Glaucoma,” Grant and Burke discussed the importance of personalizing glaucoma care to the needs of each patient and the severity of glaucoma. In the intervening 37 years, we have learned much more about not only the individual response to glaucoma but how our society and health care system play important roles in determining the course of glaucoma in patients. Using a “failure mode” analysis, we can identify opportunities where patients with glaucoma can be better screened, care initiated, follow-up care provided and social resources mobilized to reduce the burden of glaucoma-related vision loss not only for individuals but for our population in the United States and globally. In leading a team approach to care, we can also rediscover the joys of practicing medicine that will keep our profession vigorous and patient-focused amidst the tremendous changes underway in medicine and health care. By asking “why,” we can find new ways of addressing long-standing challenges so that glaucoma will no longer be the second leading cause of blindness (first among blacks) in the United States.
The Centers for Disease Control and Prevention (CDC) funded two grants for Wills Eye Hospital to perform and study outreach and screening in underserved communities in Philadelphia. In the first project, examinations and treatment were performed in 4 dozen community centers and gathering places across underserved regions of Philadelphia over two years. In the second trial, subjects were screened in primary care offices in a dozen public health centers across Philadelphia and referred to local ophthalmologists. In the second project, screening over 900 subjects led to over 500 subjects being referred for further evaluation of glaucoma, diabetic retinopathy, cataracts, and other eye diseases. Given the proven issue of retention of patients within the system after positive screenings, half the subjects were assigned a social worker to aid in follow up. Preliminary data shows a dramatic improvement in follow up with the aid of the social worker. Additional findings include a high prevalence of glaucoma and glaucoma suspect, narrow angles, diabetic retinopathy and cataract. Detailed analysis showed that screening could be achieved at relatively modest cost.
PM - Anterior Segment Presentations
Professional Practice Gaps: We obtained feedback from NEOS members and discussed with the Program committee to identify potential practice gaps that include an update on anterior segment issues including complex cataracts, malpositioned implants, artificial iris, problems with premium lenses and difficulties related to cataract surgery.
PROGRAM OBJECTIVES: The content and format of this educational activity has been specifically designed to fill the identified practice gaps in our membership’s current and potential scope of professional activities in a way that focuses on education, while maintaining independence from promotional activities and commercial proprietary interests. This program seeks to:
1. Present a review of anterior segment surgical and presurgical problems and outline strategies for diagnosis and effective treatment.
2. Review current trends in the management of problems related to various cataract implants.
3. Review new anterior segment surgical issues such as the artificial iris.
Modern cataract surgery and advanced technology intraocular lens (IOL) options provide not only improved vision and quality of life, but also the possibility of reduced spectacle dependence from astigmatism and/or presbyopia correction. Comorbid ocular pathology, however, can decrease refractive outcome predictability and degrade vision quality, especially with multifocal IOLs. Fuchs' dystrophy is a bilateral cornea endothelial disorder that can present on a spectrum - with minimal findings and no associated symptoms to profound corneal edema and vision loss.
What happens when advanced technology IOL results are compromised by Fuchs’ dystrophy or corneal edema? What can be done if Fuchs’ dystrophy or corneal edema is present and patients desire premium IOL outcomes?
This presentation discusses several such cases.
When the capsule ruptures during cataract surgery, we can all agree that if vitreous prolapses forward, the first step is to perform a vitrectomy. But what should be done next? There is no consensus on the optimal IOL implantation technique in the absence of adequate capsular support, when an IOL cannot be safely placed within the capsular bag or in the sulcus. There are numerous options, including ACIOL placement, iris-fixation, and scleral-fixation, each of which has distinct advantages and challenges. This talk will briefly cover some pitfalls of using ACIOLs, including malposition, irregular astigmatism, corneal decompensation, and cystoid macular edema. Iris-sutured and scleral-sutured IOL fixation will then be reviewed, followed by a discussion of the sutureless scleral-fixation techniques known collectively as intrascleral haptic fixation (ISHF). These ISHF techniques include the glued IOL technique introduced by Agarwal and the double-needle flanged haptic technique introduced by Yamane. This case-based presentation will include several surgical videos.
Modern day cataract surgery is a highly successful procedure with great satisfaction rates for both the patient and surgeon. However, there are many circumstances where the type of cataract is more complex and understanding a systematic approach to tackling these cases is critical. In this lecture various forms of complex cataract case videos will be presented including, zonulopathy (traumatic, pseudoexfoliation, iatrogenic), white intumescent cataract, brunescent cataract, and intraoperative complications such as posterior capsule tears and suprachoroidal hemorrhage management. Preoperative considerations and perioperative management will be discussed as well as appropriate and safe surgical technique.
This lecture will focus on managing patients with malfunctioning and malpositioned IOLs. Often the care of this patient population is delayed or denied due to the perceived surgical risk associated with treatment. However, delay in care can lead to significant visual discomfort and, in the case of malpositioned IOLs, irreversible ocular damage. The malfunctioning IOL portion will include pseudophakic dysphotopsia and IOL opacification. The malpositioned IOL case presentations will include management of early and late dislocations. Preoperative testing and counseling, perioperative technique and postoperative management of this complex patient population.
Helen K. Wu
Ocular surface disease is common in patients seeking cataract surgery. The presence of preexisting dry eye or other ocular surface disease may affect preoperative keratometric and topographic measurements, leading to potential errors in astigmatism or lens implant calculations. A compromised ocular surface may also adversely affect quality of vision through multifocal lenses, leading to significant patient dissatisfaction. In addition, preexisting ocular surface disease may be exacerbated by cataract surgery, leading to such potential risks as infection and corneal melting, particularly in patients with underlying autoimmune or neurotrophic disorders. It is thus imperative to recognize and treat ocular surface disease preoperatively, so as to assure optimal outcomes.
The diagnosis of ocular surface disease may be made using a variety of tests, including patient symptom questionnaires, tear break up time, Schirmer testing, conjunctival staining, and tear film osmolarity. Imaging studies such as meibography and confocal microscopy may be helpful in delineating disorders of the Meibomian glands or corneal nerves. Clinical signs should guide the choice of treatment options. A stepwise approach utilizing artificial tears, anti-inflammatory agents, punctal occlusion, treatment of blepharitis and meibomian dysfunction, and autologous serum tears and other compounded medications may be utilized. Systemic immunosuppressant agents may be necessary in patients with severe preexisting ocular surface disease and underlying systemic autoimmune and inflammatory disorders.
Special considerations are taken into account when planning for cataract surgery in a patient with keratoconus. In mild keratoconus, one must be aware of the implications previous or future collagen cross linking can have on the cornea. Aiming for mild myopia is preferred in these patients given the hyperopic shift which occurs with corneal flattening after crosslinking. In a patient with stable and mild keratoconus who will not need crosslinking, a toric lens implant can be considered if: 1.) spectacle refraction was stable and satisfactory prior to cataract development; 2.) biometry is reliable and consistent with multiple modes of measurement; 3.) the patient will not wear a rigid contact lens in the future. An extended depth of field or multifocal lens implant is inadvisable in patients with corneal ectasia of any degree.
Moderate keratoconus patients should be aimed for moderate myopia given a more posterior effective lens position than expected based on IOL calculation formulas. In addition, fitting a rigid myopic lens is easier and better tolerated compared to a rigid hyperopic lens. It is ideal, but not always possible, to have the patient suspect rigid lens use several weeks prior to biometry.
In those with severe keratoconus (candidates for PKP or DALK), keratoplasty would ideally be performed prior to phacoemulsification. This will allow for more accurate lens calculations and a better refractive outcome. If the cataract surgery is to be done prior to, or in tandem with, keratoplasty, it is recommended to power the lens implant with an arbritrary K value of roughly 44D rather than using the Ks from the steep, ectatic cornea. This will prevent high hyperopia following keratoplasty. Intraoperatively, the peripheral cornea can be thin and the view can be poor, thus secure wound closure and the use of capsular staining can be helpful.
Uveitis-Glaucoma-Hyphema (UGH) syndrome, caused by chafing of the iris against an implanted intraocular lens (IOL), is rarely reported in children. We show a video demonstrating the etiology of UGH in an 11-year-old-boy who presented with persistent uveitis after extraction of a traumatic cataract and implantation of a sulcus IOL at the age of 8. Specifically, atrophic areas of the iris oscillated with every eye movement leading to chafing against the IOL. Typical treatment involves explantation of the IOL. However, we demonstrate that a daily mydriatic restricted iris movement and resolved the UGH syndrome. This novel treatment paradigm allowed retention of the IOL, preservation of vision, and may be another option for treatment of UGH.
Surgical management of large iris defects has been a challenging task for most surgeons with little access to appropriate technology to assist these patients. Large iris defects can be caused by congenital and degenerative disease, trauma and surgical iatrogenic trauma. Often patients struggle with debilitating glare and poor cosmesis. An opaque or colored contact lens can be utilized, however, this option is not tolerated in most patients. Further, the devices previously available for compassionate use were difficult to access, implant and achieved poor cosmesis. The HumanOptics Artificial Iris device has recently gained FDA approval and provides excellent safety and cosmesis. This lecture will address the preoperative considerations, perioperative fixation techniques and postoperative management of this exciting technology.