Reporting live from the ASCRS Winter Update on the Riviera Maya
ASCRS 2010 Winter Update hits record numbers despite fierce winter storm

Editors’ note: This Meeting Reporter contains original reporting by the EyeWorld News Team from the 2010 ASCRS Winter Update Meeting, Playa del Carmen, Mexico.

ASCRS opens the meeting with a welcome reception





Winter Update attendees visit the exhibit hall to learn about innovative products during the breaks; exhibitors take the time to offer one-on-one demonstrations or just a friendly discussion.






Attendees enjoy great breakfasts and coffee breaks in the exhibit hall every morning allowing them to network with friends, visit exhibitor booths, or simply enjoy a quiet cup of coffee

Riva Lee Asbell takes time during a break to answer questions from her discussion on E & M codes; Winter Update offers many opportunities for attendees to interact with the faculty in groups or one-on-one




Dr. Mieler opens the retina session at Winter Update with details on managing posterior segment disease

Attendees evaluate products during the break




Dr. Condon explains how to take advantage of capsular tension segments









The epic snowstorms on the East Coast and numerous flight delays didn’t prevent many attendees from reaching Playa del Carmen









Expert panel discusses IOLs, rings, and segements. Clockwise, from top left, Nick Mamalis, M.D., Bobby Osher, M.D., Gary Condon, M.D., Alan Crandall, M.D., Roger Steinert, M.D., and Stephen Lane, M.D.

Despite fierce winter storms on the northeast coast of the U.S. that grounded planes and shut down airports, attendance at the third ASCRS Winter Update Meeting in Playa del Carmen, Mexico was up. Cataract and refractive surgeons returned to what has come to be a popular intimate meeting for important news and clinical information in a relaxed setting, where attendees have easy access to the experts.

Things to put in the bag: IOLs, rings, and segments

The morning session began with a discussion on IOLs currently being used as well as those that may become available in the future. Nick Mamalis, M.D., professor of ophthalmology, John A. Moran Eye Center, Department of Ophthalmology & Visual Sciences, University of Utah, Salt Lake City, did a quick review of the accommodating lenses currently available, namely the CrystaLens (Bausch & Lomb, Rochester, N.Y.) and the Tetraflex (Lenstec, St. Petersburg, Fla.) lens, both of which are single-piece lenses. He noted that although the lenses attain some movement, they do not provide adequate near vision.
Dr. Mamalis said that the way to achieve real accommodation is with a kind of a dual optic system. The first lens of this kind that will become available in this calendar year, he said, is the Synchrony lens by Abbott Medical Optics (AMO, Santa Ana, Calif.). Currently in Phase III studies the lens comes with an innovative injector system unique to this lens, which helps put the complex device inside the eye, Dr. Mamalis said. The mechanics of the lens is based on muscle contraction: when the ciliary muscles contract, the zonules relax, and the optics will come apart, giving the patient near vision and then as the ciliary muscles relax, the zonules become more taut and the optics come together, providing distance vision. The initial results with this lens are very promising, he said.
Another completely different concept he mentioned is the basis of the NuLens from Israel, which derives its mechanics from physiology of water birds (i.e., penguins). Because penguins have to see both on land and in water, they have to change the way their lens behaves. These birds have a very soft lens and a very firm pupil. The lens literally bulges into the pupil to give them adequate vision when they're jumping into the water, Dr. Mamalis said. NuLens functions as the chamber fills up with a soft silicone gel, which then bulges forward and provide near vision. Another concept is exhibited by the PowerVision lens (PowerVision, Belmont, Calif.) that has large haptics with a reservoir of silicone-like material. Upon contraction of the zonules, the material is forced into the central part of the optic, which then gives the patient near vision, Dr. Mamalis said. Alternatively, SmartLens (Transitions Optical, Pinellas, Fla.) functions as a hydrophobic acrylic material that expands. The idea is that the lens is compressed at room temperature and inserted in a small incision in the eye. The combination of body temperature and balanced salt solution causes it to slowly, in a controlled fashion, unfold resulting in a biconvex lens that can mimic the natural human crystalline lens.

Refractive surgery: the next decade

Corneal topography can be used as pre-op screening for cataract surgery in several ways. Helen Wu, M.D., assistant professor of ophthalmology, Tufts University School of Medicine, and director of the Refractive Surgery Service, New England Eye Center, Boston, Mass., discussed some of these applications including astigmatism assessment for incision placement or toric IOL placement, assessment for corneal irregularities, which may limit success of multifocal IOLs, assessment of irregular astigmatism to ascertain loss of BCVA and the calculation of IOL power for post-refractive surgery patients. If patients are unhappy with their results after cataract surgery, corneal topography can also be used for pre-op assessment of astigmatism for enhancement surgery. Dr. Wu also talked about some of the different types of topography systems available.
Placido-based imaging is the most commonly used system, she said. Usually, axial maps as opposed to tangential maps are used because the latter tend to smooth out any irregularity. Overall, these systems only image the anterior surface of the cornea. There are more sophisticated data analyses now that can help us identify patients who might be at risk for keratoconus. Elevation maps, on the other hand, show height of the cornea above a computer generated shape and that shape can be derived from either a scanning slit technology, Scheimpflug images, or a grid projected onto the cornea and the cornea power is then determined from the shape, she said. As for scanning slit technology, the Orbscan was the first one to image the posterior surface as well, as do the Scheimpflug technologies. However, she said, sometimes these elevation maps alone without concurrent Placido disc image may cause subtle but very important clinical variations (like central islands) to be missed. The Orbscan combines the Placido technology with scanning slit technology and has about 9000 data points. Looking at both the front surface elevation maps and the back surface can help surgeons determine who may be a good future candidate for laser vision correction later. Scheimpflug technology uses a rotating Scheimpflug camera, which supplies 3-D pictures of the whole anterior segment in order to provide additional information compared to what's on the cornea, Dr. Wu said.
Speaking on limiting dry eye problems following LASIK, Stephen S. Lane, M.D., said that several studies have shown that regression following both hyperopic and myopic LASIK is correlated with dry eye. Although, he added, that not all studies have shown this is the case. However, dry eye is a prevalent condition that pre-exists in 38 percent to 78 percent of patients prior to LASIK and affects more than half of LASIK patients, he said.
The FDA recommends advising patients of post-LASIK dry eye (among other post-procedure side effects). Physicians can limit dry eye following LASIK by screening patients for pre-disposing risk factors and treating pre-existing dry eye prior to the procedure, Dr. Lane said. The risk of post-LASIK dry eye and its consequences can be mitigated by appropriate pre-op patient screening, surgical technique and post-op treatment, he added Glimpsing into the future of presbyopia correction, Charles R. Moore, M.D., International Eyecare Laser Center, Houston, Texas, discussed the early results of his experience with an off-label PresbyLaser procedure using the wavefront optimized excimer laser (Alcon Laboratories Inc.). Dr. Moore said he conducts the procedure on bilateral virgin eyes only and the goal is to achieve increased negative spherical aberration as well as increased negative Q value. Three-month results showed 97% of eyes had 20/25 binocular UCVA, while 85% were J3 or better. There was no loss of BSCVA, and Dr. Moore said that it is a safe and effective procedure. Along similar lines, Eric D. Donnenfeld, M.D., co-chairman, Cornea, Nassau University Medical Center, East Meadow, N.Y., and Ophthalmic Consultants of Long Island, N.Y., discussed multifocal LASIK for presbyopia correction using a variable spot scanning excimer laser. Dr. Donnenfeld introduced some results of a VisX (AMO) clinical trial. Performed in the non-dominant eye, the patients have found a significant improvement in their near vision in their non-dominant eye and basically no effect on distance vision, he said. The hyperprolate peripheral ablation provides a 2-3 line increase in near vision. It is a safer technology, without need to double card, has no risk of decentered ablations, and incurs less loss of contrast sensitivity, Dr. Donnenfeld said.

Editors’ note: Drs. Donnenfeld and Mamalis have financial interests with several ophthalmic companies. Dr. Moore is the US national medical monitor for Alcon (Fort Worth, Texas). Dr. Wu has financial interests with Alcon, BD Ophthalmic (Franklin Lakes, N.J.), and Refractec (Irvine, Calif.).

Sessions continued at the third ASCRS Winter Update meeting in Playa del Carmen on Saturday. Attendees got an in-depth update on healthcare reform issues in Congress, as well as practical approaches to complications in the anterior segment and glaucoma.


Legislative and regulatory update

On the second day of ASCRS Winter Update 2010, Nancey K. McCann, ASCRS Director of Government Relations, highlighted key issues in healthcare and Medicare reform of concern to ASCRS, ophthalmology, and the medical community today. On top of the list is the repeal and replacement of the sustainable growth rate formula (SGR). ASCRS, along with the entire physician community continues to advocate a permanent SGR solution, she said.
Congress enacted a temporary 2-month reprieve from the 21.2% cut that was originally scheduled to take effect on January 1, 2010. However, if Congress does not act, the cut is now scheduled to go into effect on March 1, 2010. The Senate leadership had originally intended to include another 7-month extension as part of the Jobs bill, but it was recently removed due to objections by the Republican leadership. She reported that their goal is to enact a short term fix, along with other “extenders” in separate legislation before the end of the month. She reiterated, however, that the physician community is opposed to any short term fix that only exacerbates the problem and causes the cost of a long term fix to continue to increase. She reviewed the top issues that were identified by ASCRS and the physician specialty community in the Senate and House health care/Medicare reform legislation and also pointed out that the current health care/Medicare reform direction is to move to a system of value, not volume, focused on primary care. She reiterated that this is bi-partisan. The priorities of ASCRS include the repeal and replacement of the SGR, opposition to the creation of an Independent Medicare Advisory Board, opposition to a budget-neutral bonus to primary care, opposition to a mandatory Physician Quality Reporting Inititiave (PQRI), and support for continued patient access to and choice of specialty physician. She went on to explain that ASCRS supported the House legislation, because all of the priority issues were addressed in a favorable manner. The Senate bill, however, did not, and in fact, included additional provisions that would negatively impact ophthalmology and specialty/surgical medicine, therefore, ASCRS and the majority of the specialty community opposes the legislation. The creation of an Independent Medicare Advisory Board, which is embraced by the Obama administration, is made up of unelected officials appointed by the President that would have control over Medicare spending. McCann explained that the Board would have to achieve a certain percentage of savings every year, and it would be their responsibility to determine how that savings would be achieved. Congress would have limited ability to overrule the proposals. ASCRS and the surgical specialty community has opposed this from the very beginning and has been very clear that if this provision is in any healthcare reform bill, it will oppose that legislation, she continued.
ASCRS also opposes the primary care bonus that is based on budget neutral funding, she said. Budget neutral funding means that no new money is used to pay for the provision, so reimbursement to other physicians is reduced to fund the increase. Budget neutral funding means it’s not paid for. Another concern is that the physician quality recording initiative (PQRI) does not become a punitive system, because it isn’t working now, she said, it should remain voluntary. Legislation in the Senate calls for it to become punitive after several years and ASCRS and the medical community is opposed to this. Finally, the Society supports continued patient access to and choice of specialty physicians.
In terms of the outlook for reform, McCann said, despite the outcome of the recent election in Massachusetts, which reduced the number of Senate Democrats to 59(60 is required to invoke cloture in the Senate), the House and Senate leadership continues to consider alternatives to moving health care reform. The House could pass the Senate bill as is and try to “fix” issues in other legislation, they could use budget reconciliation, which would only require 51 votes in the Senate, the House and Senate could start over to try to find compromise on a significantly scaled back bill, or there could be a total collapse in health care reform legislation, but that remains to be seen. President Obama is to meet publicly with Democrats and Republicans and independent experts on February 25 in an effort to develop a possible bi-partisan proposal. The areas of focus for discussion include insurance reform, cost containment, expanding coverage, and assuring that any health care reform proposal does not add to the deficit. ASCRS’ action plan is that it is not committed to any promised future support and will evaluate each step as it develops. It will continue to work with the surgical and specialty community with respect to mutual priorities and continue to work to improve a final health care reform bill if there is one. Final legislation will be evaluated based on the ASCRS principles, she said.
McCann also asked attendees to contact their members of Congress when asked to do so because they need to hear from the constituents. “They care about how this affects you, your practice and your patients,” McCann said.

Surviving disaster: practical approaches to dealing with anterior segment complications and challenges

As the session shifted focus to clinical applications, attendees learned practical approaches to dealing with anterior segment complications. In case of a malpositioned IOL, Walter J. Stark, M.D., Boone Pickens Professor of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, described a method of fixing the lens to the iris, while Stephen S. Lane, M.D., adjunct professor of ophthalmology, University of Minnesota, Minneapolis, described a sclera-fixation technique.
Dr. Stark said in cases where there is inadequate capsular support, he sutures the IOL to the peripheral iris using a modified McCannel technique with a 10-0 Prolene suture. The technique is accomplished through a 3.5mm central incision, he said. It permits secondary IOL insertion in aphakic patients who are contact lens intolerant, facilitates the management of IOL problems after surgery that require IOL exchange, and allows the surgeon to properly treat patients who develop loss of capsule support at the time of cataract surgery. Though Dr. Lane said the transcleral fixation technique is something everyone should know, it sometimes isn’t practical to do. Instead, he explained a scleral pocket fixation technique, which he said is equally applicable to situations where there is a lack of capsular support. The new minimally invasive technique includes a simpler creation of suture knot covering, which avoids the need to rotate knots. It also involves no conjunctival dissection or sclera cautery, and instead entails an easier dissection of the distal fixation site. There are no sutures in the flaps as well. The technique works for the repair of dislocated IOLs, the implantation of secondary IOLs, and the repair of iridodialysis.
Attendees also learned how to deal with an IOL exchange with an open posterior capsule. Marc A. Michelson, M.D., Birmingham, Ala., described a method where the Sheets’ Glide is used to create an artificial posterior capsule to assist with the procedure. He discussed a case study where the tool was successfully used.The management of the atypical cataract was also discussed in the session. Robert H. Osher, M.D., professor of ophthalmology, University of Cincinnati, and medical director emeritus, Cincinnati Eye Institute, described how to avoid an Argentinian Flag Sign when encountering a white cataract. Dr. Osher said in such cases, the endocapsular pressure needs to be neutralized by using a viscoelastic to flatten the lens dome and retard the capsule’s tendency to run downhill.
During a question and answer session, Dr. Lane, who moderated the discussion, had the expert panel of speakers answer one particular question from the audience: Since you guys take care of a lot of disasters, what is the one thing community ophthalmologists can do better or stop doing? Their answers were as follows: Don’t YAG as a knee jerk reaction to a problem after cataract surgery (Dr. Osher) Learn how to treat the vitreous (Nick Mamalis, M.D.) In case of emergency, have important tools like stains and hooks available (Alan S. Crandall, M.D.) 1-piece lenses should stay in the bag (Marc A. Michelson, M.D.) Set the expectations of patients and understand your own limitations, referring if it is appropriate. (Dr. Lane) There is a temptation to promote premium lenses because of the ability to charge a lot more for them, but there is a temptation that is overwhelming some of our colleagues to promote and push products that really aren’t a good match for the patient. We need to use the lenses that are right for our patients. (Roger F. Steinert, M.D.) Push yourself and stay current and see if you can try to do more of some of these advanced techniques (Jonathan B. Rubenstein, M.D.) If you have problems and are worried about decentration, use a 3-piece lens. (Dr. Stark)

Everyday decisions in glaucoma: a case study approach

For comprehensive ophthalmologists, the day’s session ended with discussions on everyday decisions in glaucoma. Apart from learning about techniques in the early detection of glaucoma, attendees also heard about what to do in situations where there is confusion in the work up for atypical optic nerves and visual field defects with normal IOP. One of the situations Adam C. Reynolds, M.D., Intermountain Eye and Laser Centers, Boise, discussed was when to suspect compressive disease and get an MRI. He said that this is usually in cases where the patient is male, 55 or younger, there is asymmetric disease with more pallor than cupping, loss of color vision or central acuity not fitting with the amount of optic nerve damage or field loss, field loss pattern not typical for glaucoma and very low yield in older patients with more typical bilateral glaucomatous findings.
To differentiate focal glaucomatous notching from optic pits, Dr. Reynolds said there is retraction of retinal pigment epithelium (RPE) with pits with a “grey” appearance, very focal defined defects on nerve fiber analyzer (NFA) and visual field, abnormal vessel distributions with asymmetry between nerves, and true glaucomatous notching has more classic visual field defect and usually there are abnormalities in the other eye.

Editors’ note:
Drs. Lane and Osher have financial interests with several ophthalmic companies. Dr. Stark has financial interests with Alcon (Fort Worth, Texas) and Lux Biosciences (Jersey City, N.J.).

Sessions at the 2010 ASCRS Winter Update meeting continued on Sunday. After a valuable session on practice management and reimbursement, attendees garnered pearls on cataract case complication management and posterior disease management in the anterior segment patient.


Reimbursement pearls

Attendees learned valuable practice management information as Riva Lee Asbell, ophthalmic reimbursement consultant, principal of Riva Lee Asbell Associates, Philadelphia and Fort Lauderdale, gave a brief overview of E/M codes and went into detail about some important eye codes and the rules with which to use them. Physicians then came away with an algorithm that would help them optimize reimbursement at their practices.

Video symposium: challenging cataract cases & complication management Moderator Robert H. Osher, M.D., professor of ophthalmology, University of Cincinnati, and medical director emeritus, Cincinnati Eye Institute, presenting several videos to demonstrate ways in which he managed to deal with certain complicated cases. An expert panel discussed the various options available to surgeons in those situations.
Some pearls included avoiding accidental detachment of the cannula, which can cause real damage. In addition, Dr. Osher showed two cases which exhibited signs of TASS development upon follow-up after routine implantation of a Toric lens with no complication during surgery. After some investigation, it was discovered that reusable cannulas were the cause. Dr. Osher and panelists advised physicians to use disposable cannulas wherever possible to prevent such situations from occurring. Dr. Osher also showed a case where a routine cataract surgery in an RK patient had a +5.0 D result. The advice from panelists was to wait for stabilization in such cases. Dr. Osher said that upon follow-up, this patient was +4.0 D at 1 week, roughly +3.0 D at 2 weeks, roughly +2.0 D at 3 weeks, roughly +1.0 at 4 weeks and finally settled down with +¾ D. She was uncorrected 20/20 and an extra depth of field that is common in RK patients.

Management of posterior segment disease in the anterior segment patient

Shifting focus onto the retina, Walter J. Stark., M.D., Boone Pickens Professor of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, discussed the results of a recent study, published in the Archives of Ophthalmology, which he conducted with colleagues, on the progression of AMD following cataract surgery. Concerned with conflicting retrospective study results on whether cataract surgery makes macular degeneration worse by increasing progression, Dr. Stark and colleagues prospectively studied patients with non-neovascular AMD who were awaiting cataract surgery. They performed fluorescein angiography preoperatively and at the postoperative week 1, month 3, and month 12 visits. The primary outcome measure was the incidence of neovascular AMD development within 12 months after operation. Dr. Stark said that results showed a low incidence rate of neovascular AMD development between 1 week and 1 year following cataract surgery and therefore did not support the hypothesis that cataract surgery increases the risk of AMD progression. Several eyes appeared to have disease progression on post-op week 1 fluorescein angiograms, and Dr. Stark said it suggested many cases of presumed progression to neovascular AMD following cataract surgery may have been present prior to cataract surgery, but wasn’t detected earlier because of lens opacity.
The good news for these types of patients, he said, is if they have significant cataract, that physicians can inform them that there’s a 5% chance that they will have progression of macular degeneration but it does not appear that cataract surgery itself increases that. Dr. Stark said he tells his patients that by taking the cataract out, the Snellen visual acuity and contrast visual acuity should improve. He said his practice is getting a little more liberal in taking out the cataracts in those patients who may get down to the 20/50 to 20/60 range and hopefully get them to about 2 lines of Snellen. These patients do benefit from cataract surgery, said.
Brendan J. Moriarty, M.D., consultant at Leighton Hospital in Crewe, Cheshire, U.K., talked about the safety and efficacy of three intraocular telescopes for macular degeneration, including the IOL Visually Impaired Persons (IOL VIP), the Implantable Miniature Telescope (IMT), and the Lipschitz Macular Implant (LMI). Of the three, only the IMT will be available in the U.S. Dr. Moriarty said that when using these intraocular telescopes, physicians should set realistic expectations, be prepared to reject patients who aren’t good candidates, pick patients that are highly motivated.
William F. Mieler, M.D., University of Illinois at Chicago, Chicago, discussed the prevention and treatment of cystoid macular edema (CME) in cataract surgery as well as how to deal with diabetic macular edema (DME). Dr. Mieler said it is important to identify the causes of inflammation and other precipitating factors and commence treatment before irreversible macular damage occurs.

Glaucoma question and answer

How to decide when to treat suspected glaucoma: Both Doug Rhee, M.D., and Adam Reynolds, M.D., referred to the ISNT rule of the optic nerve. What is the ISNT rule? A normal optic nerve follows the "ISNT" rule of neuroretinal rim thickness (from thicker to thinner rim): inferior>superior>nasal>temporal. Discs that deviate from this classic appears may have glaucomatous damage.
Primary and secondary therapy including laser trabeculoplasy: What is your laser regimen? The panelists primarily use the SLT laser 360 degrees, approximately 100 spots. Barb Smit, M.D., titrates the laser power according to the pigmentation of the TM to the point where there is a mild, visible response (champagne bubbles).
What are contraindications to laser trabeculoplasty? Inflammatory glaucoma, neovascular glaucoma, blood in Schlemm's canal, extremely heavy pigmentation (if SLT is performed, must be very low power and limited clockhours), poor access to the angle.

Editors’ note:
Dr. Osher has financial interests with several ophthalmic companies.
Drs. Chomsky, Stalk, and Moriarty have no financial interests related to their presentations. Dr. Mieler has financial interests with Alcon (Fort Worth, Texas), Allergan (Irvine, Calif.), and Genentech (San Francisco, Calif.).