March 12-13, 2021 Conference


AM Session - Ethics and Risk Management (includes OMIC Lecture)

Program Objectives: 1. Improve strategies for addressing ethical and medical legal challenges presented to us by the global COVID-19 pandemic. 2. Increase the ability to manage stress and to recognize/manage burnout. 3. Increase the audience’s ability to ethically manage patients with limited resources. 4. Recognizing the ethical issues involved in private equity. 5. Improve understanding of the ethical issues in the delivery of volunteer eye care.


Introduction of Session
Mary K. Daly

"The Academy’s Code of Ethics" - A Historical Perspective
Charles M. Zacks

The Academy’s Code of Ethics is soon to be 40 years old, spanning the careers of most practicing ophthalmologists today. While the bedrock principles of medical ethics have not changed since Hippocrates, a detailed practical approach to ethics in ophthalmology is a moving target – requiring adaptation to the specific professional developments and prevailing societal conditions that affect our daily practice. The origins and history of the Academy’s Code of Ethics will be reviewed, with emphasis on some important additions and revisions to the Code in response to these changing conditions. This review will demonstrate the importance of the Academy’s ongoing efforts to actively maintain the Code as “living document”, in order to provide maximally relevant and useful guidance to currently practicing and new ophthalmologists, as well as to the future generations of ophthalmologists that will succeed us.


Introduction of the B. Thomas Hutchinson Lecture and GOH, David W. Parke II, MD
Mary K. Daly

COVID-19, Ethics, and Ophthalmology
David W. Parke II

The COVID-19 pandemic produced a plethora of ethical challenges for physicians. Whereas few were entirely ‘new’, many had been contemplated either in the abstract or in association with limited (and frequently geographically and culturally remote) populations. Many issues, such as prioritizing access to limited and potentially life-saving resources, did not generally involve ophthalmology to any great degree. Other physicians, however, dealt daily with issues such as end-of-life conversations, withdrawing ventilator care, privacy concerns with contact tracing, and vaccine prioritization. Ophthalmology and the American Academy of Ophthalmology were faced with a number of ethical conundra during the ‘COVID era’ that it had never previously confronted. On some occasions ethics collided uncomfortably with economics, access to care, quality of care, and nonmedical issues. Sometimes it meant balancing the issues of physicians, patients, the profession, and communities. History (if it cares) may judge that not all the ‘right’ decisions were made, but they were made trying to keep fidelity with articulated principles. Some of these dilemmas focused on balancing the needs of individual patients versus society itself as the COVID-19 pandemic focused on population health rather than individual health needs. This basically posed the question “What is the individual ophthalmologist’s and the Academy’s greater moral and ethical responsibility—to advocate for the needs of ophthalmologic patients or to back away in the face of other/greater public health concerns?” Others dealt with the relative focus on ophthalmology diseases and procedures in an environment of limited resources. Another facet of this issue was the consideration of ‘urgency’ of ophthalmic care. For example, should we and how should we determine when cataract surgery is nonurgent versus urgent? And how is this modulated when any surgical procedure enhances the risk of transmission of a potentially lethal viral disease? The COVID-19 pandemic also was associated with a focus on significant societal issues of racism, diversity, and disparities in health care. It posed for each of us (and for the Academy) issues balancing professional scope of activities versus societal obligations. How wide is our lane? These (and other issues) combined to constitute the ethical challenges for ophthalmology and ophthalmologists of the COVID-19 pandemic era.


COVID-19 Vaccine Development: Ethical Considerations
Dan Barouch

Ethics of Innovations While Managing the COVID Pandemic by the Chief of Surgery at a Public Health Commission
Vincent J. Patalano II

Abstract: The Cambridge Health Alliance (CHA) is a quasi-governmental public health commission and integrated healthcare system providing care for socio-economically disadvantaged populations including many non-English speaking immigrants in Boston’s Metro North Area. During the first few months of the COVID Pandemic in 2020, the communities where CHA provides care were epicenters of infection in the State of Massachusetts. Dr. Jim Patalano, an ophthalmologist, has been the Interim Chief of Surgery at CHA since November 2019, including the twelve months of the COVID Pandemic so far. He will discuss major changes and innovations in the delivery of healthcare adopted early at CHA to meet the exceptional challenges and stresses, including some ethical considerations.


Private Equity (PE) and Ophthalmology: Current Status and Issues (Part I)
David W. Parke II

Private equity (PE) fund acquisition of practices in comprehensive ophthalmology and optometry and in the retina subspecialty have transformed the discussion of eye care delivery in recent years. Most transactions have occurred since 2016 and several practice aggregations have already been resold completely or partly to subsequent buyers (a process generally referred to as ‘recapitalization’). It is a national phenomenon with acquisitions now in over 45 states and with development into multi-state practice entities. The asset sale of practices to PE firms is only one aspect of consolidation in health care delivery—of individual practices into large practices, of practices into networks of practices, of practices with outpatient centers (ASC’s, long-term care facilities, imaging centers, etc), of practice networks with hospital systems (so-called ‘integrated health care systems), and even incorporating insurance products. The process is sometimes referred to as “corporatization”— when acquisition involves companies in capital markets. The process, done carefully, does not violate corporate practice of medicine statutes due to exemptions provided and by the interposition of management services organizations in the successor structures. PE purchases of ophthalmology practices date back almost a decade. In radiology PE purchases have occurred for over 20 years, with a particularly large transaction volume in 2007. PE has been active in many other specialties over decades including emergency medicine, dermatology, orthopedics, cardiology, gastroenterology, urology, and primary care. The ‘hottest’ areas now are ophthalmology and dermatology. Some maintain that this is nearly identical to the sale of practices to physician practice management corporations in the 1990’s. That’s not really accurate. And sale of a practice to investor-owned entities is fundamentally different than sale to nonprofit integrated healthcare systems. Those systems share an underlying healthcare mission without an annual return of profits to external passive investors. (Although in some respects they can behave like for-profit corporations.) PE-owned practice operations focus primarily on annual return on investment to fund investors and then (generally 3-6 years later) an investment exit through sale of practice assets to another investor—a process over which the physician has no control. The impact on patients and society remains largely anecdotal. However, it is reasonable to presume that the path to increased financial return involves some combination of positive experience of care, marketing, decreased expenses, increased volume of services, improved payer mix, and increased payment per patient visit. Clearly, some of these appear to be conflicting objectives. The ultimate impact on cost and quality of investor-owned healthcare, regardless of the imperative, must be determined but will be methodologically challenging. For practice owners, sale of the practice results in an upfront payment for assets—generally a mix of cash and equity. This engenders a subsequent lower compensation per unit of work performed, because a portion of the future income stream has been sold as a part of the initial financial transaction. For some, it will translate into less time spent managing a practice with less input into practice operational decisions. For younger, nonpartner ophthalmologists, the outcome is different. There is generally no upfront payment, their future revenue stream has already been discounted (although retention mandates a competitive compensation), and a pathway to control of the practice doesn’t exist. It also frequently impacts (for financial reasons) decisions such as site of surgical service, timing and choice of capital equipment, use of Part B drugs, and models, levels, and compensation of office staffing. The approximately 1,300 ophthalmologists whose practices have been acquired by PE firms represent a small fraction of the over 18,000 ophthalmologists in practice in the United States. However, when one considers that at least 20% of all ophthalmologists are employed by large nonprofit systems including academic health centers, the Veterans Administration, and the military, this is a material percentage of the whole. Ophthalmologists are motivated to explore PE transactions for a host of reasons—exit strategy, fear that they own a depreciating asset, need for professional management, IT concerns, access to capital for practice expansion, desire to exit practice management, and any combination of the above. For some it is simply ‘fear of missing out’ (FOMO).


Ethical Issues in Volunteer Eye Care
Paul Cotran

This talk will discuss the ethical, moral, and practical aspects of providing charitable eye care with lessons learned from years of medical missions in El Salvador and Haiti. Although organizers of missions are often focused on obtaining supplies, staffing, and equipment, we also need to pay attention to questions of equity and fairness, patient advocacy and privacy, differences in culture and language, and the often hazy legal status of volunteering to work in resource-limited countries. Do patients in the medical mission setting have the same rights and protections as they have in the US? How do we avoid the “dependency trap” of donating eye surgery, medications, and corrective eyeglasses when the long term goal is for each country to be able to provide quality, accessible eye care for its own citizens? How should we collaborate with in-country partners and hosts to create a sustainable eye care delivery model that improves local eye care capacity—and ultimately reduces the need for our direct intervention. The current pandemic has forced our volunteer organization to consider these questions with increased urgency, and to come up with new models of helping our partners abroad.


Unpaid Medical and Surgical Services What are your Options?
Christopher J. Soares

This talk will discuss the topic of unpaid medical and surgical services. We will investigate the patients who do not pay their bills and what physicians can do to try to maximize their collections. We will review billing and coding regulations and proper ways to manage patients who have not paid their bills.


Private Equity (PE) and Ophthalmology: Current Status and Issues (Part II)
David W. Parke II

Private equity (PE) fund acquisition of practices in comprehensive ophthalmology and optometry and in the retina subspecialty have transformed the discussion of eye care delivery in recent years. Most transactions have occurred since 2016 and several practice aggregations have already been resold completely or partly to subsequent buyers (a process generally referred to as ‘recapitalization’). It is a national phenomenon with acquisitions now in over 45 states and with development into multi-state practice entities. The asset sale of practices to PE firms is only one aspect of consolidation in health care delivery—of individual practices into large practices, of practices into networks of practices, of practices with outpatient centers (ASC’s, long-term care facilities, imaging centers, etc), of practice networks with hospital systems (so-called ‘integrated health care systems), and even incorporating insurance products. The process is sometimes referred to as “corporatization”— when acquisition involves companies in capital markets. The process, done carefully, does not violate corporate practice of medicine statutes due to exemptions provided and by the interposition of management services organizations in the successor structures. PE purchases of ophthalmology practices date back almost a decade. In radiology PE purchases have occurred for over 20 years, with a particularly large transaction volume in 2007. PE has been active in many other specialties over decades including emergency medicine, dermatology, orthopedics, cardiology, gastroenterology, urology, and primary care. The ‘hottest’ areas now are ophthalmology and dermatology. Some maintain that this is nearly identical to the sale of practices to physician practice management corporations in the 1990’s. That’s not really accurate. And sale of a practice to investor-owned entities is fundamentally different than sale to nonprofit integrated healthcare systems. Those systems share an underlying healthcare mission without an annual return of profits to external passive investors. (Although in some respects they can behave like for-profit corporations.) PE-owned practice operations focus primarily on annual return on investment to fund investors and then (generally 3-6 years later) an investment exit through sale of practice assets to another investor—a process over which the physician has no control. The impact on patients and society remains largely anecdotal. However, it is reasonable to presume that the path to increased financial return involves some combination of positive experience of care, marketing, decreased expenses, increased volume of services, improved payer mix, and increased payment per patient visit. Clearly, some of these appear to be conflicting objectives. The ultimate impact on cost and quality of investor-owned healthcare, regardless of the imperative, must be determined but will be methodologically challenging. For practice owners, sale of the practice results in an upfront payment for assets—generally a mix of cash and equity. This engenders a subsequent lower compensation per unit of work performed, because a portion of the future income stream has been sold as a part of the initial financial transaction. For some, it will translate into less time spent managing a practice with less input into practice operational decisions. For younger, nonpartner ophthalmologists, the outcome is different. There is generally no upfront payment, their future revenue stream has already been discounted (although retention mandates a competitive compensation), and a pathway to control of the practice doesn’t exist. It also frequently impacts (for financial reasons) decisions such as site of surgical service, timing and choice of capital equipment, use of Part B drugs, and models, levels, and compensation of office staffing. The approximately 1,300 ophthalmologists whose practices have been acquired by PE firms represent a small fraction of the over 18,000 ophthalmologists in practice in the United States. However, when one considers that at least 20% of all ophthalmologists are employed by large nonprofit systems including academic health centers, the Veterans Administration, and the military, this is a material percentage of the whole. Ophthalmologists are motivated to explore PE transactions for a host of reasons—exit strategy, fear that they own a depreciating asset, need for professional management, IT concerns, access to capital for practice expansion, desire to exit practice management, and any combination of the above. For some it is simply ‘fear of missing out’ (FOMO).


Maintaining Sanity in a VUCA world
Susannah G. Rowe

For many physicians, novel stressors from COVID have only exacerbated chronic underlying distress and burnout due to pre-existing dysfunction in the practice of medicine. Ophthalmologists are no exception; our rates of burnout and reduced professional fulfillment were on par with other specialties before the pandemic, and this year, together with many of our colleagues, we have experienced significant COVID-related risks and impacts on our profession. In addition to COVID we have faced myriad other challenges, many of which impact us differentially depending on our circumstances, and many of which we have no control over. We are all experiencing significant stress, although we do not all feel it in the same way or to the same degree. Many of us have survived the last year in crisis mode, fueled by adrenaline as we move from one seemingly insurmountable challenge to the next. While this strategy offers many benefits in the short term, remaining indefinitely in crisis mode costs us dearly in the long run. A different approach is possible: in situations where we have little or no control over our stressors, we still have total control over how we respond to the stress. Choosing strategies that allow our bodies and minds to rest and recover between crises has been shown to prevent longer-term stress-related injuries and illnesses, and to help us function optimally when we need to. When we manage our own stress well, the people around us benefit as well. The most effective strategies for managing individual stress vary from person to person. Fortunately, many tools are now available to help us explore possibilities and learn what works best for each of us. By the same token, much has been learned about how health care organizations can best support their workers’ wellbeing, and about what leaders can do to help their teams through such an extended crisis, and beyond.


AM Session - Glaucoma

Program Objectives 1. Review of supplements and cannabis in regards to glaucoma treatment. 2. Review of treatment algorithms for severe stage glaucoma patients. 3. Review of treatment algorithms for normal tension glaucoma patients.


NEOS President Introduction
Jorge Arroyo

2-day meeting introduction.


Session Introduction
Manishi Desai

In todays AM session we plan to cover topics that affect us in our daily glaucoma practices. The material covered will provide hopefully new insights as well as serve to refresh and/or reinforce our knowledge about these everyday challenges.


When Testing Does Not Match – What Next?
Michael Lin

Often in glaucoma, the clinical examination will correlate with structural and functional testing. However, optical coherence tomography and automated visual field testing can often produce results that do not match with each other or with the clinical examination. This talk provides a brief tour through potential pitfalls in glaucoma testing that may come up during clinical practice, drawn from the presenter's own clinic. Topics covered include assessing for incorrect testing setup, poor technical performance of visual field testing, imaging artifacts in optical coherence tomography, atypical patient anatomy complicating testing interpretation, and other diseases masquerading as glaucoma.


What to do with the advanced stage glaucoma patient?
Geoffrey Emerick

The stakes are high in advanced glaucoma. Vision loss is often symptomatic and functionally significant. Patients and their family members are worried about potential loss of productivity and independence, and about treatment costs. Progression can be devastating yet hard to detect given visual field fluctuation and the ‘floor effect’ of peripapillary OCT. Once other equally serious diagnoses are ruled out, management can be challenging. Sufficient IOP reduction will usually halt glaucoma progression but is usually not attainable with MIGS alone; multiple medications and/or higher risk filtering procedures may be required. Coexisting conditions such as ocular surface and macular disease require a multipronged approach to care, and vision rehabilitation services should be offered as early as is appropriate.


We Need to Screen for Glaucoma in the Community
David Friedman

This talk will review the benefits and challenges of screening for glaucoma in at risk lower income communities. Nearly 50% of those with glaucoma are undiagnosed and brining them into care is an important public health concern. The process is complicated, though and requires efforts not only to identify those with glaucoma, but to figure out ways to ensure they receive needed care.


My Patient Has Normal-Tension Glaucoma (NTG) and Worsening - What Next?
Sonalee M. Desai-Bartoli

NTG has traditionally been classified as a subset of POAG. We will discuss how NTG differs from POAG by 1. Underlying systemic comorbidities 2. Prognosis and risk of visual field progression 3. Optimizing treatment options beyond IOP


When Your Patient Asks, "What Can I Do for my Glaucoma?"
Kristy Mascarenhas

The use of complementary and alternative medicine (CAM) for glaucoma has been increasing over the last several decades, and patients often ask for their physicians’ opinions on CAM and lifestyle modifications at office visits. This talk aims to familiarize physicians with the evidence for and against these treatments, so that we become more comfortable discussing them with our patients. Topics will include vitamins, supplements, herbals, dietary changes, and other lifestyle modifications.


NEOS Guest of Honor Introduction
Manishi Desai

Dr. Pasquale is current director of ophthalmology at Mt. Sinai as well as Deputy Chair of Ophthalmology Research at Icahn School of Medicine at Mt. Sinai, Director of the Mt.Sinai/NYEE Eye and Vision Research Institute.


How to Provide Virtual Glaucoma Care With Virtually No Glaucoma Tools
Louis Pasquale

The COVID-19 pandemic has been the catalyst for providing virtual medical care. The ecosystem that enables virtual ophthalmic care includes 5G networks, the internet of things and artificial intelligence (AI). Yet gaps in glaucoma care (virtual or not) remain including the need to move beyond in-office point estimates of intraocular pressure, the performance of visual fields in the comfort of home, and the generation of self-fundus photos that could be subjected to an AI algorithm. The objective of this talk is to offer practical advice to clinicians on leveraging the existing ecosystem in the delivery of ophthalmic care with special emphasis on glaucoma.


Precision Nutrition in Glaucoma Management
Louis Pasquale

There is no consensus on the role of nutrition in glaucoma prevention and glaucoma management. There are many reasons for this including imprecision with the measurement of nutrient intake, the chronic course of glaucoma and the fact that the role nutrition may play in glaucoma depends on genetic background. The field of glaucoma has experienced a remarkable resolution of the genetic architecture for primary open-angle glaucoma and it’s endophenotypes (intraocular pressure and cup-disc ratio), allowing us to explore whether there is a role for personalized nutrition recommendations for glaucoma based on their genetic makeup. The objectives for this talk are to review the status of nutritional glaucoma epidemiology, the status of knowledge regarding glaucoma genomics and present the latest data on gene-diet interactions in glaucoma.


Chandler-Grant Introduction
Janey Wiggs

Chandler Grant Lecture: "Peering Beyond the Blindspot Seeking Authentic Risk Factors: A Case Study".
Eve J. Higginbotham

This past year has been a year like no other, given the confluence of the COVID-19 pandemic, the effects of climate change, and the national reckoning related to the impact of four centuries of structural racism. This presentation will probe the question of the use of “race” in science and medicine and review of 20 years of the Ocular Hypertension Study, as an opportunity to consider lessons learned about the value of inclusive leadership, constructive uncertainty, and biologically-measurable risk factors related to glaucoma. In her case study she will highlight the outcomes of this clinical trial which uncovered a new biologically measurable risk factor. This is intended to be a lecture that will inspire future thinking about the use of the term, “race” in science and medicine.


Hey Doc, What About Marijuana?
Matthew Leidl

The endocannabinoid system (ECS) is a complex network that regulates numerous physiologic processes. Marijuana achieves its effects through the ECS, and it was incidentally noted in the 1970s that smoking marijuana can reduce intraocular pressure (IOP). Following this, researchers have worked for years to better understand the ECS and to identify relevant compounds for the treatment of glaucoma. This presentation will review the ECS, studies of the role of cannabinoids in management of glaucoma, and the public’s perceptions about the utility of marijuana use for glaucoma.


Panel Session - Glaucoma: 'Everyday Challenges'
Manishi Desai

Annual Board Meeting Presentation 2020-2021
Jorge Arroyo

We have been working hard to provide you with greater value.


PM Session - Neuro-Ophthalmology Emergencies

Program Objectives: 1. Review the required history-taking, examination, and “next-step” decision making in common neuro-ophthalmic emergencies 2. Familiarize the audience with novel or evolving emergent entities in neuro-ophthalmology


Introduction of Session
Marc Bouffard

Triaging Diplopia
Elizabeth Fortin

Cf objectives.


Triaging Anisocoria: Causes, Clinical Evaluation, and 'Next Step' Management
Eric Gaier

Anisocoria (interocular difference in pupil size) is a common neuro-ophthalmic sign that may represent one of many different benign or malignant underlying pathologies with implications for systemic disease. Unilateral disruption of sympathetic pupillary innervation causes miosis, whereas disruption of parasympathetic pupillary innervation causes mydriasis. Sympathetic and parasympathetic efferent pathway disruptions are distinguishable though clinical assessment and identification of specific but often subtle associated signs. Diagnostic pharmacologic testing can be used to locate lesions along these pathways and potentially distinguish causes. Specific malignant causes of anisocoria vary by clinical context and should be considered until definitively excluded through pharmacologic testing, imaging, and/or laboratory testing.


Transient Monocular Vision Loss: Causes, Evaluation and ‘Next Step’ Management
Tatiana Bakaeva

This is a brief overview of different causes of transient monocular vision loss: how to recognize them by history and exam findings, and the next steps in management.


Introduction of Guest of Honor
Marc Bouffard

Management of Acute Optic Nerve and Retinal Ischemia
Nancy J. Newman

Sudden monocular visual loss of an arterial vascular etiology is a devastating medical emergency that primarily presents to the eye-care provider. If suspecting either optic nerve ischemia or retinal ischemia, the most important first step is to assess the patient for giant cell arteritis and manage accordingly. Optic nerve ischemia can be anterior or posterior, and currently treatments are lacking. Acute retinal arterial ischemia, including vascular transient monocular vision loss (TMVL) and branch (BRAO) and central retinal arterial occlusions (CRAO), are ocular and systemic emergencies requiring immediate diagnosis and treatment. Guidelines recommend the combination of urgent brain magnetic resonance imaging with diffusion-weighted imaging, vascular imaging, and clinical assessment to identify TMVL, BRAO, and CRAO patients at highest risk for recurrent stroke, facilitating early preventive treatments to reduce the risk of subsequent stroke and cardiovascular events. Because the risk of stroke is maximum within the first few days after the onset of visual loss, prompt diagnosis and triage are mandatory. Eye care professionals must make a rapid and accurate diagnosis and recognize the need for timely expert intervention by immediately referring patients with acute retinal arterial ischemia to specialized stroke centers without attempting to perform any further testing themselves. The development of local networks prompting collaboration among optometrists, ophthalmologists, and stroke neurologists should facilitate such evaluations, whether in a rapid-access transient ischemic attack clinic, in an emergency department-observation unit, or with hospitalization, depending on local resources.


When IIH is Not Indolent: Fulminant IIH
Nancy J. Newman

Idiopathic intracranial hypertension (IIH) is a disease of unknown aetiology, typically affecting young obese women, producing a syndrome of increased intracranial pressure without identifiable cause. The goals of management are to help alleviate symptoms such as headache, pulsatile tinnitus and diplopia and to prevent visual loss, usually in the form of visual field constriction. Although most patients with IIH will have a relatively benign course of the disease, up to 97% of patients will have some visual field abnormalities from progressive, insidious visual loss from chronic papilledema. However, approximately 3% of IIH patients will have severe and rapidly progressive visual loss within 4 weeks of symptom onset. These “fulminant” cases require prompt and aggressive management, usually with urgent surgical intervention (optic nerve sheath fenestration, CSF shunting procedures or venous sinus stenting). Recognizing these patients at presentation is essential to avoid devastating visual loss and devastating medical legal consequences.


When is Optic Neuritis an Emergency? Stratifying the Risk of AQP4 Seropositivity as a Guide to Early Treatment
Bart Chwalisz

2021 marks the 30-year anniversary of the publication of the optic neuritis treatment trial, a landmark publication that has yielded a wealth of information about the presentation, natural history and treatment of typical optic neuritis. However, the landscape of optic neuritis has changed over the last two decades with the identification of aquaporin 4 antibody-mediated neuromyelitis optica spectrum disorder (NMOSD), and then even more recently with the addition of MOG (myelin oligodendrocyte glycoprotein)-associated disease (MOGAD) as other common causes of optic neuritis. Given the differences in the clinicoradiologic profile and outcomes between typical optic neuritis, NMOSD and MOGAD, new approaches are needed to accurately diagnose and treat patients with optic neuritis.


Giant Cell Arteritis
Nurhan Torun

GCA is the most common systemic vasculitis in the elderly and may result in irreversible vision loss, aortitis, myocardial infarction, stroke or death. The most commonly recognized ophthalmic manifestations of GCA include ischemic optic neuropathy, central retinal artery occlusion and constant or intermittent diplopia. GCA can be a diagnostic challenge for clinicians, especially when the presentation is atypical or occult. Despite the fact that it is an invasive and time consuming test with suboptimal sensitivity, temporal artery biopsy is still considered by most experts to be the gold standard in the diagnosis of GCA. Based on recent literature, both traditional and new vascular imaging modalities hold promise as noninvasive diagnostic methods. Tocilizumab has been found to reduce the cumulative glucocorticoid exposure and increase the rate of sustained remission.


Neuro-ophthalmologic Complications of Immune Checkpoint Inhibitors
Philip Skidd

Immune checkpoint inhibitors have revolutionized survival for patients with advanced tumor types. This novel class of medication acts to prime the immune system to better identify and attack the tumor. In doing, the immune system not uncommonly turns on self as well. Immune related adverse reactions are common side effects of these medications. Ophthalmic and neurologic complications have been described and there is growing literature describing a broad spectrum of signs and symptoms related to these. Specific neuro-ophthalmic adverse reactions are uncommon, and may present with syndrome-like presentations. Recognizing this unique risk and potential for treatments of these complications is the goal of this talk.


Atypical, Fulminant Toxic Optic Neuropathies: Tacrolimus, Amiodarone, and Methanol-induced Optic Neuropathies
Geetha Athappilly-Rolfe

Toxic optic neuropathies are typically characterized by gradual, symmetric, central vision loss that often can improve, when the causative agent is identified and stopped early. Atypical fulminant optic neuropathies present differently, with more rapid onset, severe vision loss, and life threatening complications in the case of methanol toxicity. Furthermore, with amiodarone and tacrolimus the presentation may look similar to a non-arteritic optic neuropathy, preventing stopping the medication in a timely manner that could recover vision. Therefore, it is especially useful for eye doctors to be aware of the medications and toxins that can cause atypical optic neuropathies.


Radiation Optic Neuropathy
Crandall Peeler

Patients with a history of radiation treatment for brain, sinus, orbital, or intraocular tumors are at risk for delayed vision loss from radiation-induced optic nerve injury. A cumulative radiation dose of 50 Gy appears to be the threshold beyond which optic nerve injury occurs, though lower levels of exposure may still result in vision loss in patients receiving concurrent chemotherapy and in those with advanced age, comorbid diabetes, or tumors compressing the afferent visual system (1,2). On a cellular level, ionizing radiation damages the replicative machinery of actively dividing cells. Susceptible structures within the optic nerve include vascular endothelial and glial cells. Both histologic studies, which show swelling and loss of vascular endothelial cells in sections of radiation-exposed optic nerves, and magnetic resonance imaging, where contrast enhancement demonstrates a breakdown of the blood-brain barrier, suggest that vascular dysfunction and hypoxia are the primary drivers of optic nerve injury (3). Available treatments for radiation optic neuropathy are lacking, so an awareness of the risks and prevention strategies are crucial in protecting the sight of patients undergoing radiation therapy. Delivering radiation in numerous, small fractionated doses and taking advantage of new radiation techniques that minimize collateral damage to surrounding tissues are the best strategies to preserve vision.


Panel Discussion: Neuro-Ophthalmology
Marc Bouffard

PM Session - Practice Management: Survival in a Challenging World

Program Objectives 1. Providing practice management tips from a variety of practice types to improve quality of care. 2. Discussing strategies to adapt to rapidly changing reimbursement and regulations. 3. Reviewing how practices have adapted to the COVID-19 pandemic.


Introduction to Practice Management Session
John T.H. Mandeville

The practice of ophthalmology, like so many things in our lives, is undergoing rapid change and evolution.  These include reduction in reimbursements, increasing regulatory burdens, adjustments in workflow due to the COVID-19 pandemic, scope of practice issues and shifting patient expectations and online reviews, to name a few.  While all of us are experts in giving clinical care, we are rarely educated about the best ways to deliver that care and manage the practices to which we belong.

As the first-ever NEOS session on Practice Management, we will be addressing some of the biggest challenges that we face from the perspective of practice management.  Our expert speakers include managing partners, chief medical officers, presidents, department chairs, owners and an ophthalmologist-in-chief.  They come from solo practice, group practices, academia, private equity partnership and multi-specialty hospital groups with a great breadth of knowledge.  

Everyone of us is a leader in our practice to some degree or other, and we can all learn from the pearls shared by these experts today to improve the care we deliver and the functioning of our practices.

PROGRAM OBJECTIVES:

  1. Providing practice management tips from a variety of practice types to improve quality of care.
  2. Discussing strategies to adapt to rapidly changing reimbursement and regulations.
  3. Reviewing how practices have adapted to the COVID-19 pandemic.

 


The Multispecialty Hospital-Based Practice
Shiyoung Roh

Ophthalmology is a vertically integrated division within the larger department of surgery at the Lahey Hospital & Medical Center. The practice is designed as a multispecialty group made up of ophthalmologists and optometrists, with fellowship trained subspecialists in retina, glaucoma, cornea, neuro-ophthalmology, oculoplastics, clinical electrophysiology, and low vision. As a designated Level I trauma center certified by the American College of Surgeons, our busy multispecialty group practice is further enhanced by being part of a multi-disciplinary 24-7 surgical team. Being a hospital-based practice also allows for interdisciplinary care of the patient who requires access to multiple specialists and teams to manage complex conditions, including inpatient care. As a physician-led, nonprofit teaching hospital which is a part of the Tufts University School of Medicine, physicians also have the benefit of academic support necessary to conduct research and academic programs aimed at improving medical practice. Being a part of a large hospital-based practice also includes having specialized interdepartmental units that take care of many administrative and insurance processes, including centralized patient scheduling, international services, volunteer services, philanthropy, and research grant support. Specialized human resource liaisons aid in technician and physician recruitment within the division. This allows the doctors to focus on patient care, as well as teaching medical students, residents and fellows. But being part of a large organization also poses challenges when it comes to improving efficiency. There are many administrative barriers to getting new processes and equipment approved, which must conform to the guidelines of state and local regulatory requirements for hospitals, as well as the Joint Commission for Hospital Accreditation. Finally, although the COVID-19 pandemic posed additional challenges, as a hospital-based practice, we maintained our clinics and operating rooms for emergencies and urgent care visits. We also made changes in our clinics both for safety and improved patient flow. Following a dramatic decrease in in-person visits, we have found ways to optimize patient flow to reach 90% of pre-epidemic patient and staffing levels while meeting or exceeding all state mandated occupancy limits and recommended cleaning and hygiene protocols. Our Telehealth program also benefited from having access to equipment and communication networks, allowing us to quickly utilize and employ Telehealth visits, with technology resources necessary for its success. We expect these improvements to the way we deliver efficient and safe patient care to extend beyond the present COVID crisis.


Survival Tips from a Private Equity Partnership
Corey Westerfeld

1. What is a Private Equity Partnership 2. Recent history and trends of private equity partnerships 3. Advantages to private equity partnerships 4. Disadvantages of private equity partnerships 5. Tips for Success: Key Relationships 6. Tips for Success: Providers 7. Tips for Success: Patient Care 8. Tips for Success: Financial 9. Long term prognosis for Private Equity in Ophthalmology


Survival Tips from a Large Practice
Claudia U. Richter

Ophthalmic Consultants of Boston, Inc., believes that survival is dependent on building a resilient practice. The keys to developing a resilient practice include expecting constant change, careful financial management and frequent analysis of financial status; building a well-trained, dedicated and loyal work-force; and building patient loyalty. The large size of OCB allows us to have a professional management team to manage the business aspects of the practice on a daily basis, freeing the ophthalmologists to provide clinical care. When the pandemic struck, the highly experienced and on-site management team was able quickly to take all the necessary steps to save our practice. Ophthalmic Consultants of Boston, Inc., believes that survival is dependent on building a resilient practice. The keys to developing a resilient practice include expecting constant change, careful financial management and frequent analysis of financial status; building a well-trained, dedicated and loyal work-force; and building patient loyalty. The large size of OCB allows us to have a professional management team to manage the business aspects of the practice on a daily basis, freeing the ophthalmologists to provide clinical care. When the pandemic struck, the highly experienced and on-site management team was able quickly to take all the necessary steps to save our practice.


Introduction of Guest of Honor
John T.H. Mandeville

Dr. Robert Wiggins is the quintessential Guest of Honor to speak at the first-ever NEOS session devoted to Practice Management.  He is a successful and respected clinician, educator and administrator.  He is a national authority regarding ophthalmic practice administration.

Dr. Wiggins has trained at some of the finest institutions in the country.  He earned his medical degree from the University of North Carolina at Chapel Hill, followed by a residency in ophthalmology at Duke.  He then completed a fellowship in pediatric ophthalmology and strabismus at Baylor in addition to a fellowship in neuro-ophthalmology at Duke.  Dr. Wiggins served as a Clinical Assistant Professor of Pediatric Ophthalmology at the King Khaled Eye Specialist Hospital in Saudi Arabia for a year before joining a large ophthalmology group practice, Asheville Eye Associates in North Carolina, where he currently serves as the physician administrator. He has remained with Asheville Eye Associates since 1991, which was acquired by a physician practice management company in the 1990s and subsequently repurchased by its physicians.  While fully engaged in the practice of medicine, he went on to pursue a Masters in Healthcare Administration at UNC Chapel Hill. 

Among his many honors and awards include memberships in the Phi Beta Kappa and Alpha Omega Alpha honor societies during medical school.  He has received the Honor Award from the American Academy of Ophthalmology (AAO) and from the American Association for Pediatric Ophthalmology and Strabismus (AAPOS), where he served as AAPOS President from 2016-2017.  He has received the Achievement Award and the Secretariat Awards for Education and Practice Management from the AAO and the Marshall Parks Bronze Medal from the Children’s Eye Foundation.  He is currently the Treasurer and a Board Member of the Ophthalmic Mutual Insurance Company (OMIC).  He has also been an examiner for the American Board of Ophthalmology.

Dr. Wiggins has been a rising leader in ophthalmology through his service at the AAO.  He served on the Practicing Ophthalmologists Advisory Committee (2008-2012).  He has been very active in the American Academy of Ophthalmic Executives (AAOE), the AAO’s practice management affiliate that focuses on the educational needs of those managing the business side of ophthalmology practices.  Dr. Wiggins was the Co-Chair of the AAOE Electronic Health Records Committee and is a member of the AAOE Board of Directors.  In working with the IRIS registry, he served as the Chair of the Task Force on IRIS Registry Operations and as a member of the IRIS Executive Committee.  Dr. Wiggins held the prestigious position of Senior Secretary for Ophthalmic Practice, an AAO Board position, from 2014-2019.  He is a current member of the AAO Membership Advisory Committee.  Most notably, Dr. Wiggins has risen to the position of President-Elect of the AAO this year. 

NEOS is honored to have Dr. Robert Wiggins share his insights about practice management.


Keeping Patients, Staff, and Physicians Happy
Robert E. Wiggins, Jr.

Satisfaction in healthcare is often focused on patient opinions, particularly in the age of social media, as patients have a powerful voice in physician reputations. However, the satisfaction of other stakeholders, such as staff members and physicians, is also important since patient satisfaction depends heavily on their engagement and satisfaction with the work environment. This lecture will discuss those factors important to each group and how to balance and optimize the satisfaction of each of these groups in the ophthalmology practice.


Going Lean! Efficiency and Effectiveness in the Ophthalmology Practice
Robert E. Wiggins, Jr.

Concerns about healthcare quality and cost have moved to the forefront in discussions on the evolution of the U.S. healthcare system. It is no longer a question as to whether healthcare organizations should focus on these issues, but rather how to do so to insure their survival. The purpose of this course is to discuss the lean approach to quality improvement and efficiency. Specific examples which can be applied to your practice to reduce waste will be given to demonstrate the value of this methodology in improving both quality and efficiency and satisfaction among all the stakeholders in an ophthalmology practice.


Survival Tips from Academic Partnership
Michael E. Migliori

In the academic setting, maintaining practice efficiencies can be challenging and those challenges have been amplified during the COVID pandemic. In addition to typical practice management issues, trainees add their own unique complexities. In the dedicated resident clinic model, residents earlier in their training may take longer with each patient and require more oversight with respect to ordering and interpreting testing than their more senior colleagues. In the integrated teaching model, trainees see patients alongside the attending physician which may allow for more patients per session but increasing patient throughput increases the staff’s workload. In either case, the educational mission cannot be ignored. Efficiency and teaching are not mutually exclusive, and in fact teaching efficiency enhances resident education. This talk will explore some processes that can maximize efficiencies without compromising education.


A Solo Practitioner's View of Ophthalmology Management
Jean E. Keamy

This presentation will discuss why I chose to become a solo practitioner and to leave a multi-specialty group to do so. The benefits and drawbacks of solo practice will be examined. The management of a solo practice has definitely benefited from my MBA and product management experience prior to medical school. Some of the most useful skills such as marketing, finance, and new venture management have been particularly helpful. I hope to share some of my practice management pearls. Running a solo private practice has had its own challenges during the covid-19 pandemic. Being a solo practice in some ways made it easier to meet the challenges of the pandemic and others more difficult. A few of the pandemic challenges for a solo practice will be reviewed.


Practice Management - Panel Discussion
John T.H. Mandeville

The speaker panel will engage in a robust discussion of a range of topics, including:  

  • Call (should we be paid for it, who should be able to take it, what is our obligation to do it)
  • Telemedicine (did you use it, what platforms did you use, what patients are best suited, future utility)
  • Compensation (collections vs RVU, handling of overhead, incentivization, ASC ownership, cash procedures)

A variety of opinions will be presented.