Reporting live from the AAO annual meeting, San Francisco

Editors’ note: This Meeting Reporter contains original reporting by the EyeWorld News Team from the 2009 AAO meeting in San Francisco. Meeting Reporter is sponsored by an unrestricted grant from Abbott Medical Optics (AMO).

Subspecialty Day at the American Academy of Ophthalmology (AAO) annual meeting got underway on Friday, October 23 with topics focused on innovative uses with the femtosecond laser, statistics on refractive surgery volume, and hot topics in cornea.

Cataract surgery closer to femtosecond laser assistance

At least three different companies are developing a femtosecond laser to be used for cataract surgery. During refractive surgery subspecialty day, physicians presented different models of femtosecond lasers being developed by three different companies for refractive cataract surgery. Zoltan Nagy, M.D., deputy director, Semmelweis University, Budapest, Hungary, updated a presentation he gave earlier this year at the ASCRS annual meeting on a laser system being developed by LenSx Lasers (Aliso Viejo, Calif.). In 200 eyes, the laser successfully liquefied the lens nucleus and created reproducible sized, shaped, and centered capsulotomy. Jonathan H. Talamo, M.D., Waltham, Mass., expanded on the benefits a femtosecond laser brings to cataract surgery when introducing a laser by Optimedica Pascal System (Santa Clara, Calif.). In addition to easing nucleus aspiration and improving capsulotomies, the lasers increase a physician’s control over the capsulorrhexis, astigmatism, and cataract incisions. A third laser is being developed by LensAR Laser System (Winter Park, Fla.), said Louis D. “Skip” Nichamin, M.D., Brookline, Pa. Having been used on 59 eyes in Mexico, Dr. Nichamin reported similar results to what Dr. Nagy reported; chiefly “a more accurate and more repeatable capsular opening with a more regular shape compared to manual capsulorrhexis. The laser-cut capsule is easy to remove at the beginning of cataract surgery.”

Editors’ note: Dr. Nagy has a financial interest with LenSx; Dr. Nichamin has a financial interest with LensAR; and Dr. Talamo has a financial interest with Optimedica.

Annual ISRS/AAO survey reflects 15% drop in refractive procedures

In its ninth year, and its first year completed online, the ISRS/AAO annual survey provided insights into national trends in refractive surgery. Among the findings Richard J. Duffey, M.D., Mobile, Ala., presented included ISRS/AAO members endured about a 15% dip in refractive procedures last year. Most of the losses were seen in LASIK volume, but the drop was not “across the board” for all refractive procedures. In fact, Dr. Duffey said refractive lens exchange procedures and phakic intraocular (IOL) implantations both went up last year, to 8% and 16% of refractive procedures, respectively. The VISX laser system (Abbott Medical Optics, AMO, Santa Ana, Calif.) continues to be the most popular system, but the WaveLight system (Alcon, Fort Worth, Texas) is also gaining in popularity and last year was no different. VISX’s popularity has dropped to 2:1 ratio to WaveLight, Dr. Duffey said. In refractive multifocal IOLs, Crystalens (Bausch & Lomb, Rochester, N.Y.) remains the most popular with ReStor (Alcon) not far behind. In a distant third is the Tecnis Multifocal (AMO), which has essentially replaced the ReZoom among those surveyed, Dr. Duffey said.

Editors’ note: Dr. Duffey does not have any financial interests related to the survey.

Cornea and eye banking symposium a hot success

Study after study on important surgical techniques and technology generated lively dialogue among attendees at the Federated Symposium on Eye Banking and Cornea, which was jointly sponsored by the Eye Bank Association of American and The Cornea Society.
A new and simple method of preparing endothelial grafts that are thinner than those conventionally used in Descemet’s Stripping Automated Endothelial Keratoplasty (DSAEK), was described by Massimo Busin, M.D., Italy. Some studies have shown a correlation between thinner grafts and better visual outcomes. Dr. Busin presented results of a study where 10 of 20 matched donor corneas were assigned to each of two groups: ultra-thin (U) and control (C). Dr. Busin reported that pachymetry was comparable in both groups (P=0.6) pre-op and after the 300µm keratectomy. Average final thickness determined by histology was significantly lower (P<0.01) in the U group than in the C group (73+/14µm vs. 175+/–38µm). Endothelial cell loss was 3.6+/–3% in the U group and 3.0+/–3% in the C group. Dr. Busin concluded that grafts prepared with this technique are thick enough to facilitate surgical manipulation and become thinner than conventional DSAEK grafts when the hydration subsides. Endothelial cell loss caused by the technique is comparable to conventional preparation and lower than that reported following DMEK graft preparation, he said.
In a presentation that won the Federated Societies’ Best Paper Award sponsored by SightLife Inc., Amit Patel, F.R.C.Opth., United Kingdom, evaluated the use of endothelial grafts with stromal support for Descemet’s Membrane Endothelial Keratoplasty (DMEK). Although DMEK has the potential to enhance visual outcomes post-op compared to DSAEK, it is currently not as popular as DSAEK because of the level of difficulty in handling the thin, stroma-less endothelial graft.
On the technology side, joining in the effort to reduce endothelial cell loss during DSAEK is a new disposable donor inserter, the Tan EndoGlide (Network Medical Products, Ripon, U.K.). Donald Tan, M.D., Singapore, presented encouraging preliminary clinical results of the device, which enables double-coiling of the donor into a transplant glide chamber without endothelial touch. In a process Dr. Tan called, “similar to how a thumb drive works,” the glide chamber is inserted through a 4-4.5 mm temporal incision, with an anterior chamber maintainer, and the donor is pulled into the anterior chamber with DSAEK forceps introduced from a nasal paracentesis.
Long-term data supporting the safety and efficacy of immunosuppresion (IS) for the management of ocular stem cell transplantation (OST) patients was presented by Edward J. Holland, M.D., Cincinnati. The retrospective study included 136 patients (225 eyes) that underwent OST with concomitant IS. The patients were analyzed for demographics, IS exposure, ocular surface stability, and toxicity variables. Follow-up after OST was 53.9 months +/–32.9. At the last visit, 105 patients (77.2%) had a stable ocular surface. Mean duration of IS was 42.1 months (range 3.6 to 128.0 months). Dr. Holland recommended close follow-up and monitoring by an ophthalmologist and transplant immunologist.
This year’s Paton Awardee, Thomas Lindquist M.D., Ph.D., Redmond, Wash., won a standing ovation following his lecture on whether sterile donor corneas can be realistically attained. Following substantial data presentation, Dr. Lindquist concluded that sterile donor corneas are not yet consistently attainable. The Claes H. Dohlman, M.D., Ph.D., award for Excellence in Teaching and Education was presented to Jay Krachmer, M.D., Minneapolis.

Editors’ note: Dr. Busin has financial interests with Moria (Antony, France). Dr. Tan has financial interests with Network Medical Products (Ripon, England). Drs. Holland, Lindquist, and Patel have no financial interests related to their presentations


Subspecialty day programming continued on Saturday, October 24, at the annual AAO meeting. Among the topics covered today, innovative treatment solutions for glaucoma patients, controversies and concepts in pediatric ophthalmology, hot topics in retina, and a survey of keratoconus treatment options.

Glaucoma Day addresses challenges in glaucoma treatment

A new refillable and programmable drug delivery system for glaucoma that could also change treatment approaches to many ocular diseases in the future was described. Designed to solve glaucoma patient compliance issues, the device (REPLENISH, Pasadena Calif.), is implanted in the patient’s eye through minimally invasive surgery, and supplies the appropriate amount of drug needed at determined intervals into the anterior chamber, said Mark S Humayun M.D., Ph.D., Los Angeles. The intraocular drug pump, which is made of biocompatible material, can last between five to 10 years and can be refilled while implanted. Pre-clinical trials showed successful transconjunctival refilling every four to six weeks for a period of four to six months. In addition, Dr. Humayun said, switching medications in between refills is possible as the device is able to flush out its reservoir. In the future, the system may also be designed to include two chambers for delivery of two drugs. Concerns with the device include endothelial damage, infection, tube clogging and the amount of drug that remains in the reservoir.
Looking further into the future, Stuart J McKinnon, M.D., Ph.D., Durham, N.C., presented hope for glaucoma specialists trying to reduce intraocular pressure in their patients. Dr. McKinnon described the possibility of neuroprotective treatment for glaucoma. He explored three strategies including blocking the formation or aggregation of amyloid-β, complement activation, and tumor necrosis factor-α signalling, and said they represented considerable promise.
Felipe A Medeiros, M.D., La Jolla, Calif., described the Stratus OCT (Carl Zeiss Meditec, Dublin, Calif./Jena, Germany). He presented data that showed Stratus OCT retinal nerve fibre layer (RNFL) parameters seem to be able to discriminate eyes progressing by visual fields or optic disc photographs from eyes that remained stable by these methods, and they perform significantly better than optic nerve head (ONH) and macular thickness parameters to detect change over time. He said that these findings suggest that RNFL assessment with this technology could be useful to detect and monitor progressive disease in patients with established diagnosis of glaucoma or suspected of having the disease.
Despite certain drawbacks to EMR systems, experts in a short debate agreed that overall, adoption of the technology is beneficial to a practice. Michelle C. Lim, M.D., Davis, Calif., said EMR can help practices by providing immediate access to patient information from the office and remote locations, eliminating illegible handwriting, by offering electronic medication prescription writing and refills, and by facilitating communication between physicians. In the event that practices are able to get an EMR system custom written for them, Harry A. Quigley, M.D., Baltimore, said the adoption of the system can save time and money, and improve research capabilities. He said EMR has eliminated after-office paperwork for him because patient information is entered into the system while patient consultation is taking place.

Editors’ note: Drs. Lim and Quigley have no financial interests related to their presentations.
Dr. Humayun has financial interests with REPLENISH (Pasadena, Calif.). Dr. Medeiros has financial interests with Carl Zeiss Meditec (Dublin, Calif.). Dr. McKinnon has financial interests with Allergan (Irvine, Calif.) and Pfizer Ophthalmics (Rochester, N.Y.), among others.

Treat keratoconus with refractive options including collagen crosslinking

For patients that desire contact independence, the physician needs to identify patients with realistic expectations, that are willing to risk needing a corrective corneal transplant, have a milder form of the disease and have K readings less than 55D, said Yaron S. Rabinowitz, M.D., clinical professor, University of California, Los Angeles. In these conditions, physicians have several options including intercorneal rings (Intacs, Addition Technology, Des Plaines, Ill.), PRK, a combination of rings and PRK, topographic-guided PRK, phakic intraocular lenses (IOLs), Intralase (Abbott Medical Optics, AMO, Santa Ana, Calif.)-guided endothelial keratoplasty (IEK) and collagen crosslinking (CXL), which also can be combined with rings, Dr. Rabinowitz said. Theo Seiler, M.D., Ph.D., professor, University of Zurich, Zurich, Switzerland, provided some of the history of CXL with some pearls on patient selection. In some patients, it is necessary to do PRK after CXL, and this is usually done months later, said A. John Kanellopoulos, M.D., Athens, Greece. However, by combining the two procedures on one day, Dr. Kanellopoulos said he was able to improve uncorrected visual acuity (UCVA), BSCVA and corneal haze among other aspects. For combining procedures, he said first he remove the epithelium by topography-guided PRK, a partial ablation, application of mitomycin C (MMC), and then the CXL. CXL is yet to be approved by the Food and Drug Administration, but clinical trials remain underway.

Editors’ note: Drs. Seiler and Kaellopoulos have no financial interests related to their comments. Dr. Rabinowitz has financial interests with Abbott Medical Optics (Santa Ana, Calif.).


Sunday, October 25, brought robust and comprehensive programming on the first official day of the 2009 American Academy of Ophthalmology (AAO) annual meeting. Attendees were provided opportunities to learn about cataract surgery anesthesia, glaucoma hot topics, and femtosecond tips & tricks.

Residents lacking in premium IOL, pediatric cataract procedure experience

Third year residents are not getting enough hands-on experience leading pediatric cataracts and implanting premium intraocular lenses (IOLs) according to Vinay A. Shah, M.D., University of Missouri, Kansas City, Mo., and his colleagues. Dr. Shah sent a survey to every third year resident accredited with the Accredited Council for Graduate Medical Education (ACGME) in the United States; 154 (35.5%) of the 434 residents completed the survey. Through this self-reported survey, residents responded that they were getting ample chances at extra-capsular cataract extraction (ECCE) with 40 residents having done more than 50 surgeries. But in terms of pediatric cataract surgery and premium IOL implantation, their experiences were lacking. For example, 102 residents never implanted a premium IOL, and all but seven residents had implanted premium IOLs in 10 patients or fewer. Similarly, 118 residents never performed a pediatric cataract surgery, and only three residents had done more than 10 procedures.

Editors’ note: Dr. Shah does not have any financial interests related to this study.

New and controversial in glaucoma

During the next decade the field of glaucoma will have a definition for glaucoma diagnoses based on genetics in addition to the existing clinical, biological and epidemiologic diagnoses, said Robert Weinreb, M.D., San Diego, in his presentation on the future of glaucoma management. He said that in the future, surgeons will be transitioning to a treatment paradigm where predictive models are refined to better determine who benefits most from a treatment or advancing treatment and who does not. Evolution of a risk calculator is ongoing, he said, and during the next 10 years, new data will continue to be collected and refined to create an effective tool that glaucoma specialists can use in their clinical practice. Central to this, he said, will be the collection of genetic data. Dr. Weinreb showed data he and colleagues published recently describing a new gene linked to glaucoma in African Americans. He said he expects very shortly for the further discovery of new genes linked to glaucoma.
There will be methods for preventing the death of retinal ganglion cells and for restoring the optic nerve that are independent of the lowering of intraocular pressure, he said. He further predicted that surgeons will be able to use a cocktail of small molecules, perhaps as an eye drop and transform cells that already exist in the retina or the ciliary margins into retinal ganglion cells, without having to transplant anything. “The potential for stem cell therapy in glaucoma is vast,” he said.

Editors’ note: Dr. Weinreb has no financial interests related to his presentation.

Futuristic ophthalmic technologies and medications

Robert H. Osher, M.D., professor of ophthalmology, University of Cincinnati, Cincinnati, led a pack of leading surgeons in thoughts on emerging technology changing the landscape of clinical practice. Highlights included Dr. Osher’s praise for the Acri.Lisa (Carl Zeiss Meditec, Dublin, Calif./Jena, Germany) toric multifocal IOL. “I looked at 160 eyes,” Dr. Osher said. “It’s the real deal. You get excellent multifocality and excellent toric correction. Patients got 1.75 to 2 diopters of correction on average. And it goes through 1.5 mm incisions, so there’s no induction of cylinder.” David F. Chang, M.D., clinical professor of ophthalmology, University of California, San Francisco, provided an update on the Synchrony Dual Optic Accommodating IOL (Visiogen, Irvine, Calif.). “This is the most studied lens the Food and Drug Administration will have looked at,” Dr. Chang said. “Two different measurements show objective movement of the lens.” He expects approval is possible in a year. While the surgeons overall praised the move to smaller incisions over the years, they also noted that some of the new lens technologies will require larger incisions.
Beyond devices, the surgeons also discussed helpful new pharmaceuticals in the marketplace. AzaSite (azithromycin, Inspire Pharmaceuticals, Durham, N.C.) improves lipid reduction of meibomian glands, and it is anti-inflammatory, said Samuel Masket, M.D., clinical professor of ophthalmology, Jules Stein Eye Institute, David Geffen School of Medicine, University of California, Los Angeles. “I treat blepharitis patients preoperatively with AzaSite with great success,” Dr. Masket said. He recommended applying it to the lid margins. Xibrom QD (bromfenac ophthalmic solution, ISTA Pharmaceuticals, Irvine, Calif.) researchers have completed Phase III studies on once-a-day dosing for this topical NSAID, said Dr. Osher. “The results are fantastic,” he said. “Making patients use more drops than necessary is inappropriate. I think that’s the direction we’re heading—far less medicines on a daily basis.” Durezol (difluprednate ophthalmic suspension, Sirion Therapeutics, Tampa, Florida) is a “high concentration corticosteroid,” said Douglas D. Koch, M.D., professor and the Allen, Mosbacher, and Law Chair in Ophthalmology, Cullen Eye Institute, Baylor College of Medicine, Houston. “It’s not as prone to cause pressure spikes,” he said, adding that his clinical colleagues are using it “quite frequently on more complex cases.”

Editors’ note: The presenting doctors are investigators for the respective products they presented.


Sessions on Monday, October 26 highlighted innovative femtosecond lasers, ground-breaking lens designs, and surgical management of astigmatism.

Femto face-off

Experts argued the advantages of using competing femtosecond lasers in a face-off of the different technologies Monday. Explaining the basic differences between the currently available lasers, N. Timothy Peters, M.D., Portsmouth, N.H., said that the current IntraLase FS and Femtec systems (Technolas Perfect Vision, St. Louis) use higher-energy, lower-frequency pulses than the Femto LDV laser (Ziemer, Port, Switzerland) and the VisuMax (Carl Zeiss Meditec, Dublin, Calif.) falls somewhere in between.
Dominating market use at 91%, the newest generation of IntraLase is faster with lower energy and tighter spot separation, therefore producing better results than before, said. Daniel Durrie, M.D., Overland Park, Kan. With over 350,000 procedures having been performed using the IntraLase, there is substantial evidence for its safety and efficacy.
Arguing for the VisuMax, Dan Z. Reinstein, M.D., M.A., N.Y., said the technology provides very high flap thickness accuracy and reproducibility, fast treatment outcomes, excellent visual outcomes in combination with the MEL80 (Carl Zeiss Meditec, Dublin, Calif.), while extremely user-friendly for surgeons and affording the patient a more comfortable experience.
The formation of an opaque bubble layer (OBL) within the cornea during flap creation is a common issue with femtosecond laser technology, said Dr. Reinstein, as it can interfere with the ability of eye-tracking systems to function properly. The VisuMax, he said, produces a very thin layer of OBL, which he and colleagues have found dissipates in the time between flap-creation. There is no time wasted in the operating theatre and an average treatment time for bilateral LASIK is 12 minutes with the VisuMax and MEL80.
Speaking about the Ziemer LDV, Richard Foulkes, M.D., Chicago, said the lack of an epithelial edge gap is one advantage the technology has over the IntraLase FS. In addition, Dr. Foulkes said the technology produces no OBL or transient light sensitivity (TLS).

Editors’ note: Dr. Reinstein has financial interests with Carl Zeiss Meditec (Dublin, Calif.). Dr. Foulkes has financial interests with the Ziemer Group (Port, Switzerland). Dr. Durrie has financial interests with AMO (Santa Ana, Calif.).

Around the world

In Monday’s Around the World in 80 Minutes symposium, Ivan L. Ossma-Gomez, M.D., clinical professor, Universidad Industrial de Santander, Colombia, presented the Synchrony (Abbott Medical Optics, AMO, Santa Ana, Calif., formerly Visiogen) accommodating lens. Unlike the Crystalens (Bausch & Lomb, Rochester, N.Y.) family of accommodating IOLs —the only Food and Drug Administration (FDA)-approved accommodating IOLs—the Synchrony is a dual-optic lens, so it requires less movement to accommodate. Testing so far has found the lens to provide quality vision at a full range of distances, Dr. Ossma-Gomez said adding that it is a true capsule-filling IOL.
Another accommodating IOL being developed is the FluidVision Accommodating IOL (PowerVision, Belmont, Calif.), said Paul Roux, M.D., professor, Pretoria Academic Hospital, Republic of South Africa. The FluidVision’s accommodation mechanism is that it “forces” fluid from the “balloon” haptics to the lens by the ciliary muscles. The large haptics also make centration easy.
The lens is still in its infancy in regards to patient testing as Dr. Roux reported that it was implanted into its first four patients earlier this month.
Michael Amon, M.D., professor and head, Eye Department, Academic Teaching Hospital of St. John, Vienna, Austria, presented the Sulcoflex IOL (Rayner, East Sussex, United Kingdom).
Dr. Amon said the Sulcoflex allows piggyback implantation in pseudophakic eyes, offering exact refractive results after cataract surgery or refractive lens exchange. In a recent study of 31 eyes, after a 27 month follow up, Dr. Amon said the lens did not induce intraocular pressure (IOP) increases, and the desire vision was achieved within 0.25 D. Arturo S. Chayet, M.D., Tijuana, Mexico, presented one lens that has appeared in the United States for FDA clinical trials. The Light Adjustable Cataract Lens (Calhoun Vision, Pasadena, Calif.) is nearing the end of its Phase II trials, but it will not be available for implantation in the United States until about 2012, Dr. Chayet estimated.
This lens uses a light delivery system about one to four weeks post-operatively to adjust the IOL power. In Phase I trials, Dr. Chayet said 93% of patients were within 0.25 D of their target. Using the light powering system, the IOLs also can be powered to achieve monovision to target for presbyopic patients.

Editors’ note: Dr. Amon has a financial interest with Rayner (East Sussex, U.K.). Dr. Chayet has a financial interest with Calhoun Vision (Pasadena, Calif.). Dr. Ossma-Gomez has a financial interest with Abbott Medical Optics (Santa Ana, Calif.).