December 4, 2020 Conference
AM - Infectious Uveitis
Dear NEOS Membership, Welcome to the Virtual 782nd Meeting of the New England Ophthalmological Society. I hope that you all had a safe and enjoyable Thanksgiving! Despite all of the shocks our society has experienced over the past months, NEOS and its membership still have much to be thankful for: our moderators, guests-of-honor, speakers, and most of all our fellow members! Thank you for all that you do! We are especially pleased to have Misha Acharya, MD, as the guest-of-honor for the morning session on Infectious Uveitis and Daniel Durrie, MD as our guest-of-honor for the afternoon session on Cataract Surgery: Looking Beyond 2020. Both of these programs look outstanding and I hope you will enjoy viewing them beginning on Friday December 4th. Please leave comments for the speakers and send us any feedback you have that might help improve the virtual experience. Finally, the early COVID vaccine trial results have all been positive to date making our hope of returning to in-person meetings in 2021 feel not so far out of reach. Please stay safe until a safe and effective vaccine becomes available. With warmest Regards, Jorge G. Arroyo, MD President of NEOS
Infectious posterior uveitis may mimic other forms of immunologically-mediated posterior uveitis, such as the white dot syndromes, or primary vitreoretinal lymphoma and other masqueraders. Because of the significant implications on treatment, it is critical to differentiate infectious causes of posterior uveitis. More so, many forms of infectious posterior uveitis progress rapidly and diagnostic delays may lead to a poor prognosis. The clinical suspicion for infectious etiologies in posterior uveitis is altered based on: epidemiological considerations specific to locale, historical information, examination data, ancillary testing in the clinic, laboratory and other investigations, and lastly, ocular fluid / tissue analysis. In some cases, limited data collection in the setting of specific posterior segment morphology are sufficient for diagnosis. While in cases of atypical presentations or diagnostic look-alikes, extensive testing, including ocular fluid analysis, may be required.
Lyme disease is the most commonly reported tick-borne disease in the United States, caused by the spirochete, Borrelia burgdorferi, and is transmitted to humans through a bite from an infected Ixodes tick. It is a multi-system disorder which can affect joints, heart, and the central nervous system. The most common manifestation of Lyme in the US is a characteristic erythema migrans skin rash, which occurs in >50% of patients. Other manifestations include cranial nerve palsies, meningitis, myalgias, arthralgias, headaches, and fatigue. Although uveitis secondary to lyme is a rarely identified cause of ocular inflammation, countless patients with uveitis (and no history of tick exposure or characteristic skin rash) undergo serologic testing for Lyme disease. The widespread use of this diagnostic testing is controversial. It is expensive and often yields false positive results. Furthermore, many patients with presumed Lyme-associated uveitis are also treated with steroids, which are effective in the treatment of other forms of uveitis, so response to treatment is insufficient to conclude that Lyme was indeed causative. Lyme testing is listed as part of the “uveitis workup” in many textbooks and thus often gets ordered on many patients with any type of uveitis. Most uveitis specialists agree that testing should be limited to highly suspicious cases only. In 2013, we invited all members of the American Uveitis Society (~200 members, 158 of whom practice in the US) to participate in a study to collect data on the utility of Lyme testing in Uveitis. Four large uveitis practices in the US participated. Only subjects who had undergone Lyme testing in the workup of their ocular inflammation (uveitis, scleritis, or vasculitis) were included -- 42% had either lived in or traveled to an endemic region, 2.6% with a history of tick exposure, 5 patients with a history of possible erythema migrans. Over half of tests were obtained solely based on the presence of uveitis or scleritis. Of 546 patients on whom Lyme testing was obtained, none were ultimately diagnosed with Lyme-associated uveitis. In today’s practice, we are often met with patients who come in with a diagnosis of “Chronic Lyme” - which has no clinical definition and is not characterized by any objective clinical findings -- who see self-proclaimed “Lyme-literate doctors” who insist the patient is infected with Lyme (and often other tick-borne diseases) and desire costly, unproven, long term treatment. We must be cognizant of other, more likely causes of uveitis (i.e. idiopathic vs others). Reported cases of Lyme-associated uveitis certainly exist, however, testing should be limited to patients living in endemic areas and with a compelling history for tick exposure and associated symptoms.
This lecture will briefly review the epidemiology and clinical course of ocular toxoplasmosis, then will review the currently available treatment options of the condition, both systemic and intraocular. Different situations such as penicillin-allergy, pregnancy, pediatric patients will be addressed.
This talk will discuss the most common viral etiologies of anterior uveitis (herpes simplex, herpes zoster and cytomegalovirus and rubella). There are distinguishing clinical signs that can be helpful, including morphology of keratic precipitates. Treatment includes antivirals and low dose corticosteroids. Chronic treatment may be required in some cases.
The incidence of herpes zoster and herpes zoster ophthalmicus has continued to rise over the past 2 decades. Since the availability of vaccinations to prevent herpes zoster, the incidence appears to be declining the youngest and oldest age groups, but continues to rise in the middle-aged groups. The recombinant zoster vaccine is approved for ages 50 and older and is highly effective in preventing herpes zoster ophthalmicus.
Syphilis has been on the rise over the last decade, which has important implications for the diagnosis and treatment of uveitis. This presentation will review the clinical signs and symptoms of systemic syphilis, and the diverse clinical presentations of ocular syphilis. Attendees will also be updated on current diagnostic and treatment guidelines.
Ninani Coyne Kombo
A hypopyon is formed by a layering of white blood cells. When assessing the patient with a hypopyon it is important to review possible risk factors including trauma, surgery and systemic illness. In certain conditions, a pseudophypopyon can present. HLA B27 and Behchet's are causes of hypopyon associated uveitis.
A discussion of what we've learned about protecting HCWs from COVID-19, with a focus on PPE, other infection prevention strategies and an accurate risk assessment.
PM - Cataract Surgery: Looking Beyond 2020
Introduction of Drs. Durrie, Stevenson, Hatch, Lam, Keival, Warren and Sise.
The use of the TORIC IOL for regular astigmatism is a well-established surgical treatment for a cataract patient seeking spectacle independence. For the irregular astigmatism patient, however, including patients with conditions such as anterior basement membrane dystrophy, keratoconus, pellucid marginal degeneration, pterygium, salzmann nodular degeneration and severe dry eye, the decision is not always as straight-forward. Motivated patients seeking a reduction in spectacle or contact lens dependence with irregular astigmatism can, depending on their situation, be candidates for a TORIC IOL. Topography is an essential tool in this assessment. In some situations, a treatment such as superficial keratectomy, collagen crosslinking or ocular surface disease management followed by repeat biometry should be considered prior to cataract surgery. Setting realistic expectations for patients and having discussions as whether the patient will continue to wear contacts lenses after the procedure is critical. The unique variables and algorithms for the irregular cornea in the cataract patient with be the focus of discussion.
As we evaluate IOL technologies outside of the US, there are numerous sectors in the global market that can be looked at individually and are evaluated by market share in the industry. Additionally, the regulatory processes for IOL approvals can vary immensely in these various sectors. There are over 60 different companies across the globe developing, manufacturing, and marketing IOLs. We will explore some of the IOLs that are most commonly used and studied abroad, and also highlight some of the IOL technology that is unique with novel properties to what is available in the US. We will also pay particular focus to the IOL technology that may soon reach the US market.
As techniques and technologies continue to advance, it has become possible to offer new options to our patients to maximize surgical success and patient satisfaction. The growing interest in “dropless” options for cataract surgery has led to numerous innovations, including several corticosteroid sustained release drug delivery systems. Subconjunctival and intravitreal triamcinolone have been shown to be safe and effective alternatives to topical corticosteroids. The FDA has recently approved two novel forms of sustained release dexamethasone for use in cataract surgery. In the data reported for approval, both products compared very favorably to placebo, with more rapid and complete resolution of AC cells, reduced post-operative pain, and lower likelihood of requiring rescue therapy with topical medications. Non-steroidal anti-inflammatory drugs, while not yet available in sustained release form, continue to serve an important role in the management of post-operative inflammation. There is compelling data to support the addition of topical NSAID’s to otherwise “dropless” protocols to reduce the incidence of cystoid macular edema in patients with pre-existing risk factors.
Daniel S. Durrie
Cataract surgery is the number one volume surgery performed in the world and this movement has generated many questions focused on safety and financial viability.
The presentation will focus on providing data on the need to look for such a site of service change as well as focusing on the safety, efficacy, cost effectiveness and convenience of the experiences so far with this transition. Needed information about space requirements, equipment required, staff training, accreditation and reimbursement will be discussed.
Office based ophthalmic surgery moved from the hospital setting to ASCs in the 1980’s and 1990’s and succeeded in making surgery safer, more cost effective and a better experience for surgeons and patients. Over the next 10 years office-based surgery may become a viable alternative.
Daniel S. Durrie
The presentation will focus on three specific surgical procedures. Implantable Contact Lenses (ICL), Refractive Lens Exchange (RLE) and Refractive Cataract Surgery. The history and present state of these will be discussed as well and future developments. Who will be having these surgeries, technology that is involved and site of surgery will be discussed.
The field of surgical vision correction for improvement of refractive errors has evolved over the past 40 years. Most of the focus has been on corneal based procedures. Lens based refractive surgery options appear to be a viable option and may see significate growth over the next 10 years.
Advanced cataract care is a given in the developed world. However, millions of cataract blind worldwide cannot access surgical expertise. In this presentation, the scope of cataract blindness is reviewed, models for cataract care delivery is discussed, and MSICS surgery is reviewed.
Retina-related complications of cataract surgery are rare. They include: endophthalmitis, cystic macular edema, retinal detachment, choroidal effusion or hemorrhage, and retained lens fragments. Of these complications, choroidal effusion or hemorrhage, and retained lens fragments, are two in which actions by the cataract surgeon may help increase the likelihood of a good outcome. When a significant choroidal effusion or hemorrhage is identified, the surgical incisions should be immediately sutured closed and the surgery aborted. In the unlikely event of a severe suprachoroidal hemorrhage with very high eye pressure, immediate drainage of suprachoroidal fluid or blood may be necessary. This would entail performing a conjunctival peritomy, sclerotomy incision, and methods to encourage fluid drainage in all four quadrants until eye pressure is adequately reduced. When lens fragments are found to be falling into the posterior segment, the surgeon should not make aggressive attempts to retrieve them. It is safer to leave them for a retina surgeon to perform pars plana lensectomy at a later date. The cataract surgeon should place an intraocular lens and suture the wounds. The timing of subsequent pars plana lensectomy is dependent on many factors including eye pressure and degree of corneal edema. During a pars plana lensectomy, the retina surgeon closely inspects the retina for tears, carefully clears the vitreous from around the lens fragments and evacuates them using a fragmatome. The clinical outcome after pars plana vitrectomy is usually quite good.
Patients presenting for cataract surgery with Fuchs’ Corneal Dystrophy have different options for how to proceed with surgery depending on various factors. Most patients can benefit from cataract surgery without any corneal intervention. However, certain precautions and modifications should be adopted. DSO can provide additional vision improvement for patients with vision loss related to central guttata. Cases with more advanced Fuchs’ Dystrophy and corneal edema need a combined cataract-EK surgery.