Dec 10, 2021 Conference
AM Session 1 - THE RETINA AND SYSTEMIC DISEASE (WITH MILLER LECTURE)
- Improve ability to diagnose medical retina diseases
- Improve the ability to appropriately refer complex medical retina diseases requiring
- Increase understanding and knowledge of how systemic disease impact the retina
Manju L. Subramanian
During the start of the COVID-19 pandemic, the American Academy of Ophthalmology recommended all ophthalmologists cease non-essential care, and the American Society of Retinal Specialists followed with a similar recommendation and guidance on the types of patients and surgeries that are considered essential. Not-unexpectedly, intravitreal injections and retinal surgery rates dramatically decreased. A number of alterations to clinical and surgical care followed, including PPE, social distancing, pre-procedural COVID-19 testing. Various models of telemedicine use increased, and clinical trials were either halted or underwent protocol modifications.
Purpose:To review the literature about the combined effect of diabetic retinopathy and hypertensive retinopathy in human retina. Methods: Review of the literature Results: Numerous multicenter, prospective and cross-sectional, control studies have provided strong evidence that uncontrolled hypertension increases the risk for vision- threatening diabetic retinopathy, while pharmacologic control the blood pressure decreases the risk. Conclusions: The ophthalmologists should educate the patients with diabetic retinopathy about the importance of good blood pressure control
Manju L. Subramanian
Central serous retinopathy is a retinal condition with some underlying risk factors. We highlight epidemiologic studies discussing systemic risk factors, as well as steroid use. Using national insurance databases, we conducted a case-control study of beneficiaries with an incident diagnosis of CSR between 2007 and 2015 (n=35 492) and randomly selected controls matched on age-based and sex-based propensity scores (n=1 77 460). We discuss the hypothesized risk factors and evidence.
Choroidal Metastasis are the most common intraocular tumors. There are varied clinical presentations. Ancillary testing like OCT and Bscan can be helpful in making the diagnosis.
Eye care providers are seeing an increase in ROP due to the advances in neonatal care that allows for the survival of extreme premature babies. The use of Anti-VEGF therapy has proven to be effective and its use has increased during the past years. Anti-VEGF injections are helpful to stabilize/save the eye in unstable babies. Recent studies have shown us that there is no evidence of severe neurodevelopmental side effects after using this drugs and that they are a good alternative in the treatment of severe ROP.
Mary K. Daly
Mary K. Daly
Submacular hemorrhage occurs, despite regular anti-VEGF injections. The goal of this presentation is to discuss therapy for submacular hemorrhage, as well as surgical treatment options, including evolution of vitrectomy techniques, and in-office pneumatic techniques.
Jeffrey K. Moore
While multiple studies have reported ocular involvement in COVID-19 as well as the detection of SARS-CoV-2 in ocular swabs, evidence for posterior segment involvement is less robust. COVID-19 is known to involve endothelial cells in organs including the lung, heart, kidney and brain, and the ACE-2 receptor is present in multiple retinal cell types. Both the cytokine storm and coagulopathy induced by COVID infection can be postulated to effect the retina, and multiple case reports of posterior segment inflammatory and vascular disease following both COVID infection and vaccination have been published. It must be noted, however, that systemic conditions including diabetes and hypertension that are recognized risk factors for severe COVID infection may contribute to the retinal hemorrhages, cotton wool spots, and vessel caliber alterations that have been reported as potential manifestations of COVID-19 in case-control studies. Due to the current lack of high-level evidence, ophthalmologists should take caution before attributing new onset posterior segment disease to COVID infection or vaccination.
Manju L. Subramanian
AM Session 2 - OFFICE-BASED CORNEAL PROCEDURES
- Providing a range of procedural tools for treating the cornea in the office.
- Allowing the ophthalmologist to determine when operating room procedures are not in the patient’s best interest.
- Training the ophthalmologist to improve on established procedural techniques with recent innovations.
Michael B. Raizman
Corneal perforations are ophthalmic emergencies that may present in the office setting. Cyanoacrylate, hydrogel sealant, and fibrin adhesives can be used for small corneal perforations or leaking corneal wounds. In many cases, corneal adhesives are a temporizing measure until definitive repair in the operating room can be performed, but if the underlying condition is treated, corneal gluing can be sufficient to prevent need for more invasive procedures such as corneal patch grafts or corneal transplants to restore globe integrity. New technologies such as engineered bioadhesive hydrogels may be an alternative in the future to current corneal adhesives and offer potential advantages such as the ability to support tissue regeneration.
Calcific band keratopathy is a degenerative disorder of the cornea which leads to deposition of calcium hydroxyapatite crystals in the corneal epithelium and in Bowman’s layer. When peripheral and mild, this condition may be asymptomatic, but as the calcific material accumulates in the central cornea, it can become visually significant and can result in foreign body sensation and pain. Disodium ethylenediamenetetracetic acid (Na2EDTA) has traditionally been used to chelate and remove this calcium hydroxyapatite material from the cornea after epithelial debridement. However, cost and availability of Na2EDTA have become significant issues in recent years. Na2EDTA must be ordered in advance from a compounding pharmacy, which can be logistically difficult in many practice settings and when the procedure must be performed in resource-limited environments. A new technique published in 2018 utilizes dipotassium EDTA, which can be easily prepared using the sterile K2EDTA spray-dried in lavender-top blood collection tubes, which are widely available and inexpensive. This talk will provide step-by-step video-based instruction to help surgeons learn how to prepare and utilize K2EDTA in the clinic and operating room settings. Please note, this technique is off-label.
Amniotic membranes, both cryopreserved and dehydrated, have become readily available for use in the ophthalmology clinic. Multiple products are available from various different vendors. Approaches to the use of amniotic membranes in the clinic varies among ophthalmologists. Reported indications include dry eye, neurotrophic ulceration of the cornea, infectious corneal ulceration, delayed healing of the ocular surface after procedures such as surface ablation, and sealing of corneal perforation, among others. This talk will review the principles behind amniotic membrane use in ophthalmology and present a summary of the available evidence for its use in various clinical applications, as well as the different products available.
Microbial keratitis is an ocular emergency that can cause significant visual impairment or blindness. Identifying the pathogen is crucial to the treatment of microbial keratitis.Obtaining a pathogen is a pivotal step in the successful management of severe infectious corneal keratitis. While small corneal ulcers can be treated empirically, sight-threatening ulcers should be cultured as the first step in management. An algorithm for identifying vision threatening vs non-vision threatening ulcers can be used to determine when a corneal culture should be obtained. Having a corneal culture kit is a useful tool for any practice that sees corneal ulcers. Eye cultures are unique in that they allow identification of a pathogen from a very small sample. The kit should include tools needed to obtain a sufficient sample, and culture media for aerobic and anaerobic bacterial, fungal, amoebic, viral, and atypical bacterial organisms. Superficial scrapings may be low yield if the corneal infiltrate is deep in the stroma, non-suppurative, or there is no overlying epithelial defect. In cases when multiple cultures have been negative, a suture can be passed through the infiltrate to obtain a culture or a corneal biopsy can be performed.
High-resolution optical coherence tomography (HR-OCT) serves as a powerful tool for non-invasive in-clinic diagnosis of ocular surface tumors, especially in subtle cases or in the setting of coexisting ocular surface disease. Additionally, HR-OCT helps clinicians monitor medically and surgically treated lesions such as OSSN, and avoid premature termination of therapy to prevent recurrences.
Phototherapeutic keratectomy (PTK) was approved by the U.S. Food and Drug Administration in 1995 for use in removing anterior corneal scars or to treat recurrent corneal erosion. The 193 nm ultraviolet light (excimer laser) separates and splits molecules in biological tissue, thereby ablating it. PTK is frequently used as a method for eliminating opacities that affect the visual acuity and can create a more regular and stable surface. PTK has proven very successful in several clinical scenarios. PTK can be considered a bridge between medical and surgical management of different corneal diseases. A corneal graft can be avoided using PTK treatment to ablate superficial opacities (typically less than 100um). In addition, regrafting can be avoided by ablating recurrent pathology in the graft by excimer laser. This talk will provide an overview of the PTK procedure including indications, technique, management, outcomes as well as complications. Lastly, by optimizing PTK utilizing refractive principles, superior optical results can be achieved as opposed to conventional PTK. Cases will be shown to demonstrate the benefit of “refractive PTK”.
Michael B. Raizman
Epithelial Basement Membrane Dystrophy (EBMD) and Salzmann's Nodular Degeneration are both very common conditions seen in the clinic. They are both frequent causes of foreign body sensation, irregular astigmatism, and decreased vision. Superficial keratectomy is often performed to improve these conditions if patients suffer from recurrent corneal erosions, foreign body sensation, or have a decrease in their best spectacle corrected visual acuity. Additionally, superficial keratectomy is also often performed prior to refractive surgery to achieve a more predictable and reliable refractive endpoint. This lecture will detail some of the subtleties to consider when performing superficial keratectomy for this population of patients.
Blepharitis is an inflammatory condition of the eyelid margins that affects an estimated 20 million people in the US. It is recognized as a contributing factor to dry eye and other ocular surface diseases. Current medical treatments, including hot compresses, eyelid scrubs, hypochlorous acid sprays, and topical and oral antibiotics, are often limited in efficacy and result in poor patient compliance. Newer office-based treatments are available that offer significant benefit for relief of symptoms and improvement in meibomian gland health and eyelid appearance. This is accompanied by an overall reduction in inflammation of the ocular surface. I will discuss the most popular procedures available today and detail the benefits and barriers to adopting these modalities for an office-based practice.
Michael B. Raizman
PM Session - ADVANCES IN CORNEAL AND ANTERIOR SEGMENT DIAGNOSTICS
Nicoletta A. Fynn-Thompson
Corneal endothelial cell dysfunction can result from corneal dystrophies or from damage due to direct trauma, intraocular surgery, inflammation, or toxic insults. The resulting corneal edema leads to decreased vision, and in the case of Fuchs’ Endothelial Corneal Dystrophy, the formation of guttae can also cause glare symptoms and worsening of vision. Advanced cases of corneal edema are easily recognized at the slit lamp, but imaging tools can be useful in the detection of early corneal edema, and for the differential diagnosis of corneal endothelial cell dysfunction. Historically, central corneal thickness measurements and endothelial cell density were promoted as a means of predicting the need for corneal transplantation after cataract surgery. However, given differences in baseline central corneal thickness between individuals and populations, and local differences in endothelial cell density in the presence of guttae, these variables are likely not as predictive as some studies may suggest. Recently, Scheimpflug tomography has been shown to detect changes in corneal shape that are associated with early corneal edema and the risk of needing corneal transplantation after cataract surgery. Anterior segment optical coherence tomography (AS-OCT) is particularly useful for detecting Descemet membrane detachments and endothelial keratoplasty graft position, and is a valuable tool for confirming successful re-attachment of the Descemet membrane or Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) and Descemet Membrane Endothelial Keratoplasty (DMEK) grafts. With the advent of intra-operative OCT surgeons can also ensure full adherence of endothelial keratoplasty grafts before the end of a case, and confirm the correct orientation of DMEK grafts, which could be particularly advantageous during challenging cases with poor visibility.
This presentation will discuss the practical benefits of incorporating meibography, tear film osmolarity, and matrix metalloproteinase 9 testing into clinical practice. These tools can be used to quantify the severity of dry eye disease, a disorder when the symptoms and exam findings often do not correlate. These tools can also be used for patient education and monitoring of response to treatment.
Ocular surface squamous neoplasia (OSSN) is the most common type of malignant ocular surface lesions. The characteristic appearance of a gelatinous or leukoplakic lesion with feeder vessels makes diagnosis by clinical exam relatively straightforward. However, many lesions may have more subtle features complicating the diagnostic considerations of a benign versus malignant ocular surface lesion. Incisional or excisional biopsy with cryotherapy may be necessary in such cases to obtain a pathological diagnosis, carrying the risk of conjunctival scarring or limbal stem cell deficiency. The introduction of anterior segment optical coherence tomography (AS-OCT) has enabled assessment of the conjunctiva and cornea with high axial resolution of tissue planes. Several recent studies have demonstrated the diagnostic capabilities of AS-OCT in evaluation of OSSN with high correlation of optical images to histopathologic specimens. The use of OCT has also been studied in other applications outside of ophthalmology as a means of providing an in vivo diagnosis of carcinomas. Although histopathologic analysis remains the gold standard for diagnosis for ocular surface lesions, the application of AS-OCT as a diagnostic tool can potentially enable a non-invasive, optical biopsy for OSSN.
Nicoletta A. Fynn-Thompson
Deepinder K. Dhaliwal
With increasing patient expectations, refractive outcomes after cataract surgery have become a critical factor in the successful treatment of patients with cataracts. Cataract surgeons need to be familiar with the correction of astigmatism. There are several options available for intraoperative treatment of astigmatism at the time of cataract surgery. Corneal astigmatic incisions (CAI), including limbal relaxing incisions (LRI) and astigmatic keratotomy (AK) are used to correct low levels of astigmatism. CAI’s can either be performed with a blade or with a femtosecond laser. Toric intraocular lens is an excellent option for correction of lower and higher levels of astigmatism. Other technology such as intraoperative aberrometry, VERION image guided system (Alcon), or CALLISTO eye markerless system (Carl Zeiss Meditec) will also be reviewed.
In vivo confocal microscopy (IVCM) is an emerging technology that provides minimally invasive, high resolution, assessment of the ocular surface at the cellular level. Several challenges still remain but, at present, IVCM may be considered a promising technique for clinical diagnosis and management of infectious keratitis that will be reviewed in this presentation. Delayed diagnosis of Acanthamoeba and fungal keratitis is typical, resulting in significant vision loss. This is partially due to the low sensitivity and time delay of corneal cultures. IVCM allows prompt diagnosis, disease course follow-up, and management of potentially blinding atypical forms of infectious processes, such as Acanthamoeba and fungal keratitis, among others. IVCM is emerging as a tool for rapid diagnoses in severe infectious keratitis with high sensitivity. In addition, it can be used to monitor treatment response, allowing guidance to clinicians for medical or surgical management.
Elevation-based Scheimpflug topography is an important diagnostic tool in managing corneal ectasia and screening laser refractive candiates. Additional features, such as Belin ABCD Classification in Topometric/Keratconus Display, and Beiln Ambrosio Enhanced Ectasia Display Cornea, can provide helpful analysis in assessing keratoconus progression and subclinical keratoconus. Epithelial imaging has allowed significant improvements in our understanding of corneal remodeling. It is becoming increasingly useful in the diagnosis of subclinical keratoconus and assessing refractive surgery candidates.
Deepinder K. Dhaliwal