Reporting from the 2021 AAO Annual Meeting
November 12–15, 2021 • New Orleans, Louisiana
- State of the union on laser vision correction
- Practical insights on MIGS
- Glaucoma pipeline therapies and alternative therapeutics
- Future of refractive cataract surgery
- American Glaucoma Society Subspecialty Day Lecture
- Presbyopia correction with refractive IOLs
State of the union on laser vision correction
To kick off the AAO Refractive Subspecialty Day, Daniel Durrie, MD, gave a state of the union lecture on laser vision correction.
He first highlighted the S curve that technologies tend to follow. A lot of time and money is needed as the technology gets off the ground, he said. Then, it generally gets to acceptance and growth. But as a technology matures, it becomes hard for it to continue to move up.
He questioned whether LASIK will be left behind, as other procedures have been in the past. Dr. Durrie said he thinks this will eventually happen.
Dr. Durrie then discussed what he sees for refractive surgery in “2030 and beyond.” In corneal-based refractive surgery, he expects advanced diagnostics, automation, and AI to play a role.
He also thinks that PRK and surface ablation will survive, but he thinks there will be a shift toward femto lenticular corneal shaping. “Part of that is because there’s no epithelial defect,” he said.
Dr. Durrie said he thinks lens-based refractive surgery will likely put pressure on LASIK. Phakic IOLs are flourishing internationally, he said, adding that he also thinks refractive lens exchange/dysfunctional lens replacement will grow because “we’re all remembering that presbyopia is a lens disease.”
Many companies are updating and creating new technologies for lenticular surgery, he added, suggesting that SMILE is growing faster than other procedures.
For example, Schwind, Johnson & Johnson Vision, and Carl Zeiss Meditec are introducing updated laser technology.
“Everyone is trying to outdo the other,” he said.
Ziemer has a new lenticular procedure, CLEAR, that is CE marked as a software update to their laser. Keranova has a technology using femtosecond beams that has been used in cataract surgery and is totally robotic. The company plans on doing intrastromal refractive programs.
Looking again at S curves, Dr. Durrie mentioned how LASIK has gone through the curve and is starting to get to the point where investment is declining. At this point, he said, we have to make a decision of what to do if we stay with old technology or get stuck in the middle, or stop and change the technology, process, or paradigm to what may be an integrated system.
“We always worried about SMILE cannibalizing some of the things that we do,” he said, but where this has really occurred is with the mechanical flap LASIK.
The good news, Dr. Durrie said, is that there has been a lot of progress over the last 30 years, and procedures are safe, effective, convenient, and cost effective. “That’s why we’re growing so fast,” he said. Ophthalmology is in the middle of a technology change with refractive surgery and corneal surgery, he said, but the future looks great and it’s a great time to be a comprehensive refractive surgeon.
Editors’ note: Dr. Durrie has financial interests with Alcon, Johnson & Johnson Vision, Carl Zeiss Meditec, Bausch + Lomb, and other ophthalmic companies.
Practical insights on MIGS
Presenters in a session within the glaucoma program shared their ideal patients for various MIGS devices, along with pearls and other general information about “how we use MIGS on a daily basis,” as moderator Davinder Grover, MD, put it. Discussion ranged from stent-based MIGS to other angle-based procedures to subconjunctival MIGS.
Sahar Bedrood, MD, PhD, discussed the iStent (Glaukos), noting that this TM bypassing device has been out for a long time, allowing for a significant amount of experience and published data.
She described the case of a 69-year-old moderate myope who had mild POAG, excellent central vision, was on one drop, and whose glaucoma was not advancing. She chose the iStent for this patient due to stable disease state and good visual potential. At 2 years postop, the patient was 20/20 with an IOP of 13 mm Hg without drops.
Dr. Bedrood’s pearls for success included: 1) Magnify the angle as much as possible. 2) Hold the gonio lens and injector lightly so you don’t get striae that could impact the view for stent placement. 3) Confirm positioning; a little bit of blood, which might not always occur, can help confirm placement.
Dr. Bedrood said she analyzed 53 of her own iStent-phaco cases for more than a year and saw an average 4.8 mm Hg change in IOP with many patients off drops.
Leonard Seibold, MD, who presented on goniotomy, noted that modern day goniotomy is very different from “our grandparents’ goniotomy.” The ideal case that he brought up was a 65-year-old with pseudoexfoliation glaucoma who had been pseudophakic for 6 years. The patient’s pressures were 26 mm Hg and 20 mm Hg in the right and left eye, respectively. The goal was a pressure of 16 mm Hg. Dr. Seibold said goniotomy achieved this goal for the patient who remained on one drop postop.
Good candidates for goniotomy, Dr. Seibold said, include open angle glaucoma or pseudoexfoliation, pigment dispersion, or uveitic glaucoma patients, if they are quiet. It can be used for mild, moderate, or severe disease and can be performed whether the patient has a cataract, clear lens, or is pseudophakic. Poor candidates are patients with neovascular glaucoma, uncontrolled uveitis, elevated episcleral venous pressure, and chronic angle closure.
Dr. Seibold provided his pearls for goniotomy. 1) Optimize visualization; ensure an en face view with enough cohesive viscoelastic. 2) When getting started, tilt the blade 10–20 degrees, applying moderate outward pressure and keeping the footplate seated in the canal. 3) Use the incision as a fulcrum, pivoting in the wound, not pushing on the wound.
Dr. Seibold said the biggest strength of goniotomy is its versatility and that it doesn’t leave any hardware in the eye.
Mark Gallardo, MD, described viscodilation, which he said is especially suited for patients with corneal endothelial disease or a corneal transplant where he doesn’t want intracameral in the eye for a long period of time. Viscodilation can be performed ab externo or ab interno, he said. There are two devices that can perform the procedure: iTrack (Haag-Streit) and Omni Surgical System (Sight Sciences).
Dr. Gallardo also hailed the versatility of viscodilation, explaining that it can be performed as a standalone procedure or combined; it can be used in mild to severe OAG; it can be used after filtration surgery, following other MIGS procedures, or combined with MIGS procedures; and it does not disrupt the blood-aqueous barrier and maintains the aqueous pump.
Matthew Emanuel, MD, said he finds gonioscopy-assisted transluminal trabeculotomy (GATT) to be the most versatile of the MIGS options, given that it can be done in primary or secondary OAG, in some angle closure glaucomas, post-tube/trab or in cases of failed MIGS, and in the setting of some juvenile glaucoma. He said it is highly effective, safe, conjunctival sparing, can be performed standalone or combined, and it has the potential to be inexpensive.
His ideal first GATT patients are those with open angles with easily identifiable structures, secondary open angle glaucoma, clear corneas, and uncontrolled glaucoma. Absolute contraindications for GATT in his practice are active neovascular glaucoma and an inability to stop blood thinners, Dr. Emanuel said.
Analisa Arosemena, MD, said the XEN Gel Stent (Allergan) is indicated for patients who have failed or are unable to be controlled on maximum medical therapy. She said compared to other MIGS, it is a bit more aggressive as a bleb-creating procedure. Her criteria for ideal patients include older, Caucasian, minimal tenons, quiet conjunctiva, a target in the low- to mid-teens, preferably pseudophakic, and potentially failed on other MIGS.
She said she chooses XEN when there is a need for fast visual recovery, when there is risk of choroidal hemorrhages, anticoagulation issues, previous phaco, previous DSAEK or PKP, limited space in conjunctiva, and a need for a low, diffuse posterior bleb.
She considers the procedure a success when there is a low, diffuse posterior bleb with no subconjunctival hemorrhage. She also said the XEN has to be motile at the end of the procedure without entrapment of tenons. Dr. Arosemena said she uses heavy steroids in these cases.
Finally, Craig Chaya, MD, described why he prefers the Hydrus Microstent (Ivantis). Among various factors, he said that Hydrus has the longest safety and efficacy data, which shows that two-thirds of patients are medication free at 5 years, with a 61% reduced need for secondary incisional surgery. He said he also finds Hydrus complementary to other angle-based MIGS procedures.
Editors’ note: Drs. Bedrood, Seibold, Arosemena, and Chaya have financial interests with various ophthalmic companies. Dr. Emanuel does not have financial interests related to his comments.
Glaucoma pipeline therapies and alternative therapeutics
A session focused on medications and lasers included several presentations that looked at pipeline therapies—medications and gene therapy—and alternative therapeutics for glaucoma, such as lifestyle factors.
David Sola-Del Valle, MD, spoke about new and emerging medical therapies, starting with netarsudil, which has a three-pronged approach to IOP lowering. Dr. Sola-Del Valle said he likes netarsudil for its once-nightly dosing, efficacy at the full range of IOP, efficacy as an adjunctive agent, insurance coverage, and likelihood to be safe during pregnancy and breastfeeding. Some cons Dr. Sola-Del Valle mentioned included hyperemia, reticular endothelial edema, its expense for some patients, its white cap color, and there is no preservative-free option.
Netarsudil/latanoprost combination is also dosed once nightly, seems to work well at the full range of IOP, and mixes the two powerful medications, reducing topical toxicity, Dr. Sola-Del Valle said. Negatives include a slightly worse side effect profile than netarsudil monotherapy, side effects of PGAs, challenge of insurance coverage, white cap color, and presence of preservatives, he continued.
Latanoprostene bunod has similar pros on Dr. Sola-Del Valle’s list, but it also has less hyperemia and pain than latanoprost. Non-ideal factors he cited include that it may provide only 1.23 mm Hg of additional IOP lowering over latanoprost and its cost remains high.
In the pipeline, Dr. Sola-Del Valle also discussed sustained release. There is one sustained-release glaucoma medication that is FDA approved—the Durysta bimatoprost implant (Allergan)—but there are up to seven other delivery methods being investigated.
Dr. Sola-Del Valle also mentioned omidenepag isopropyl, a non-prostaglandin option that’s approved in Japan and being researched, and intravitreal injection of a galectin-3 inhibitor to protect the retina and optic nerve even in the setting of high IOP, currently under investigation.
Angela Elam, MD, discussed alternative therapeutics for managing glaucoma. She said that there is evidence that oxidative stress plays a role in retinal ganglion cell damage and antioxidants have been explored as neuroprotective agents. Nutrition research supports the association of increased fruit and vegetable consumption with a reduced likelihood of glaucoma. A similar association has been reported with consumption of omega-3 fatty acids, and daily consumption of caffeine in hot tea, Dr. Elam said. From an IOP control standpoint, dynamic exercise has been seen as positive, Dr. Elam said, but extreme exercises are not advisable. Dr. Elam said there has even been research showing meditation seems to have a positive effect on lowering IOP. There is conflicting evidence regarding use of gingko biloba, Dr. Elam said, and while cannabis has been shown to reduce IOP, it’s only for a short duration of 3–4 hours.
Dr. Elam advocated for more randomized control trials to demonstrate the effect for causation for many of these non-traditional glaucoma management possibilities.
Editors’ note: Dr. Sola-Del Valle has financial interests with various ophthalmic companies. Dr. Elam does not have financial interests related to her comments.
Future of refractive cataract surgery
During a keynote lecture in the refractive program, Richard Lindstrom, MD, shared his thoughts on the future of refractive lens surgery and IOL implants. He first defined refractive cataract surgery: enhancements to standard cataract surgery targeting superior vision when compared with native post-cataract vision.
Dr. Lindstrom said refractive cataract surgery is a “win” for many, including patients and their families, society, ophthalmologists, and industry.
Patients have options to improve their quality of life and increase function, he said. This can lead to longer working careers, fewer falls, and decreased spectacle dependence with enhanced quality of life.
For society, he said refractive cataract surgery can provide a higher functioning elderly population, and efforts to master refractive cataract surgery improve the standard of cataract surgery.
Ophthalmologists also see the benefits. Dr. Lindstrom said that surgeons have the opportunity to improve their skills, to offer patients new options, and deliver more value.
He added that industry also benefits from refractive cataract surgery with product development efforts focused on refractive outcomes, advanced technology options that offer incremental revenue opportunities, incremental revenue funding new product development, demand for advanced diagnostic and surgical products, and opportunities for new ventures.
Refractive cataract surgery usually includes additional costs to the provider but also additional revenue to the provider, Dr. Lindstrom said, adding that this has generated a meaningful revenue opportunity for providers and manufacturers and has been important regarding the ability to operate and stay alive in this demanding environment.
Dr. Lindstrom added that though most patients could benefit from refractive cataract surgery, not all patients can afford the additional costs associated with it. Some patients don’t see the additional value, and some cataract surgeons don’t offer refractive cataract surgery.
Dr. Lindstrom noted that refractive cataract surgery has been growing, and he highlighted the growth of presbyopia-correcting IOLs and toric IOLs, as well as the Light Adjustable Lens (RxSight). But he said there is still room for more growth.
There is a steady stream of new premium IOLs, Dr. Lindstrom said, mentioning EDOF lenses, trifocals, EDOF/multifocal hybrids, postop adjustable IOLs, shape-changing accommodating lenses, piggyback, supplemental IOLs, and small-aperture IOLs. New IOLs promise life without glasses for most people, he said, and patient satisfaction is high.
Meanwhile, the femtosecond laser is another premium offering, but Dr. Lindstrom noted that only about 12% of U.S. surgeons have adopted this technology. We’re still right at the edge of crossing the chasm where it becomes fully established procedure, he said. Dr. Lindstrom also added that there have been some major advances in diagnostics and biometry and the ability to visualize surgery.
Refractive cataract surgery is strong and growing, he said. Key market drivers include patients’ needs, demographic trends, doctors’ interests and needs, and industry revenue. New technology is changing the value equation, Dr. Lindstrom said, and there is more precision in diagnostics and surgical techniques. There are also new IOL options with better vison for patients in all ranges and less visual distortions.
Editors’ note: Dr. Lindstrom has financial interests with various ophthalmic companies.
American Glaucoma Society Subspecialty Day Lecture
The American Glaucoma Society Subspecialty Day Lecture was given by Michele Lim, MD. She focused her presentation on the use of mitomycin-C (MMC) in glaucoma procedures, especially trabeculectomy.
Glaucoma surgeons have tried all sorts of ways to achieve the ideal bleb, which is heavily reliant on modulating wound healing, Dr. Lim said. There are various methods to combat scarring, but antimetabolites and antifibrotics are most common, she said.
She said there are various methods of MMC delivery for trabeculectomy. A soaked sponge applied for several minutes is the most common method, but other methods that have been investigated include amniotic membrane application, soft contact lens, soft contact lens with sclera, and injected MMC.
Dr. Lim said when her practice started using injected MMC for trabeculectomy, she initially had some qualms. The MMC is injected with a 30-gauge needle away from the rectus muscle with the fluid spread around before proceeding with surgery.
The first study to propose MMC injection for trabeculectomy was published in 2008, but it wasn’t evaluated against a control. Dr. Lim presented three studies with a control group that were published in the time since, noting that they showed a greater decrease in IOP from baseline compared to MMC delivered via irrigation or sponge. The irrigation and sponge groups in the studies also showed more vascularized blebs than the injected MMC group. Rates of bleb leak, suprachoroidal hemorrhage, choroidal effusions, over filtration, and infection were the same among injected, irrigation, and sponge delivery groups, but injected MMC did have a higher proportion of hypotony and hypotony maculopathy, Dr. Lim said.
Does injecting MMC lead to better IOP control? Not by success-failure criteria, Dr. Lim said. Does it lead to more low-profile, diffuse blebs? Maybe, Dr. Lim said. What about bleb vascularity? There is a suggestion that it’s less, she said. Finally, does it avoid focal, cystic blebs? There isn’t evidence of that, she said.
Editors’ note: Dr. Lim has financial interests with Santen.
Presbyopia correction with refractive IOLs
William Trattler, MD, discussed pearls and pitfalls in presbyopia correction with refractive IOLs.
Some of the goals with presbyopia lenses, he said, are to achieve excellent vision, high patient satisfaction, reduction or elimination of astigmatic error, and avoidance of night vision complaints.
Pearls he discussed included preop testing, setting proper expectations, and selecting the optimal strategy for presbyopia correction. Pitfalls included preop testing, unrealistic expectations, night vision complaints, dry eye/ocular surface disease, and ending up off target.
With preop testing, Dr. Trattler said the first step is to determine whether or not the patient is a candidate for presbyopic IOL. It is therefore important to evaluate the preoperative topography, particularly looking for any dry eye and ensuring that the ocular surface is optimized.
Dr. Trattler discussed several scenarios that may appear on the topography. When looking at a pellucid pattern on topography, he said surgeons may want to avoid LRI/AK. He said these patients could receive a monofocal or toric, but a presbyopic IOL is not recommended. He also suggested excluding patients with ERM/drusen/EBMD from getting a presbyopic IOL.
Dr. Trattler highlighted different IOLs available. He mentioned that in terms of presbyopic IOLs, the Vivity (Alcon) appears to have less dysphotopsia compared to bifocals or trifocals, but it also has less range of vision.
Meanwhile, for monovision using toric and monofocals, Dr. Trattler said that the distance eye is critical, and for the near eye, he said to use a neutral aspheric or non-aspheric IOL, as it will give a little more depth of field.
He added that the Light Adjustable Lens is another option, which has the advantage of being able to adjust postoperatively.
Dr. Trattler also suggested being aware and cautious when using a presbyopic IOL in cases like a unilateral cataract, a monofocal IOL in the fellow eye, high myopes, and a fellow eye with poor vision, though it may still be possible in these cases.
Even with careful preop selection, postoperative issues can impact patient satisfaction with presbyopic IOLs. Pitfalls can include issues like residual astigmatism, residual refractive error, dry eye, floaters, night vision complaints, and patients dissatisfied with the range of vision achieved.
These presbyopic IOLs can deliver excellent visual results, he said, but patient selection is key, and patients may still not have complete satisfaction.
Editors’ note: Dr. Trattler has financial interests with various ophthalmic companies.
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