- Glaucoma innovations in the pipeline
- Addressing a range of presbyopia treatment topics
- Castroviejo Lecture
- Cornea debates
- Ophthalmic Premier League
- The role of anterior segment imaging highlighted in symposium
Glaucoma innovations in the pipeline
Over the last decade, glaucoma has been front and center in terms of the pipeline of things coming through ophthalmology, said Oluwatosin Smith, MD.
“This session is an opportunity to look and see what else is coming through the pipeline, and the things we can look forward to,” Dr. Smith added, noting that the symposium would cover sustained-release drugs, lasers, suprachoroidal implants, and more.
The first two presentations in the session took a look at innovations in the pipeline for the suprachoroidal/supraciliary space. Marlene Moster, MD, shared information about the iSTAR Medical MINIject, which is a flexible/soft, antifibrotic, medical-grade silicone implant. The implant is an “organized network of hollow spheres with a microporous multichannel matrix” that conforms to the curvature of the eye, Dr. Moster presented. She noted that a rabbit study showed 50% of the posterior implant was colonized by healthy cells, and the cells did not interfere with outflow. It is designed to extend 0.5 mm into the anterior chamber.
A series of prospective studies have been conducted with MINIject as a standalone procedure. The studies included patients with primary open-angle glaucoma who were not controlled on medications; there was no medication washout. All patients had careful endothelial cell counts and UBM to assure the implant didn’t migrate.
After 2 years, 48% of patients were medication free and 95% had pressures less than 18 mm Hg, Dr. Moster said. No additional surgeries were required, and endothelial cell count was 6%, which was comparable to other MIGS, Dr. Moster said. She also cited a low (2.4%) hypotony rate and said there is no bleb management or needling required.
Iqbal “Ike” Ahmed, MD, presented on pipeline suprachoroidal MIGS as well. First, he spoke about what has been learned since the withdrawal of CyPass (Alcon) from the market, namely the importance of a soft implant with flexibility and appropriate, stable placement in the anterior chamber.
“We know the suprachoroidal space has outflow. We know devices can drain aqueous,” Dr. Ahmed said, but he also noted the concerns with implantable hardware. The question is, can this be done without hardware?
This is what the AlloPass supraciliary biostent (Iantrek) hopes to accomplish. This technology uses sclera to act as a wick to facilitate outflow. Dr. Ahmed said that sclera is a conforming, non-hardware implant material that is soft and homologous to the surrounding tissue, making it less likely to have a fibrotic reaction.
Dr. Ahmed said the results for AlloPass are early, with only 10 patients followed for 12 months, but they showed good pressure lowering as a combined and standalone procedure. Endothelial cell loss was similar to other MIGS.
Eydie Miller-Ellis, MD, shared information about VisiPlate (Avisi Technologies), a technology that is designed to create a low, diffuse, barely visible subconjunctival bleb. This device, Dr. Miller-Ellis said, is being designed for the moderate to severe glaucoma patient as a possible alternative to trabeculectomy or tube shunt.
The VisiPlate was described as having a multichannel design (80+ channels), made out of non-fibrotic materials, with a surface area that maintains the drainage space. It is also ultrathin at 5 microns thick with patented technology to assure handleability despite its thin profile.
In a rabbit trial, Dr. Miller-Ellis said there was a significant reduction in IOP from baseline, exceeding a 20% reduction, and no MMC was used. The first in-human trial has taken place outside the U.S., and Dr. Miller-Ellis said the next step is approaching the FDA to allow clinical trials within the U.S. She also said the team is working on a surgical design that will utilize tools and techniques that glaucoma surgeons are already comfortable with.
Thomas Samuelson, MD, gave an update on the Multi-Pressure Dial (Equinox), which are goggles attached to a negative pressure pump to lower pressure in the eye relative to atmospheric pressure and relative to the rest of the body.
Dr. Samuelson said that this is a non-surgical and non-pharmacologic option to lower IOP; it can be used in conjunction with other therapies; and it is the first physics-based mechanism of action for glaucoma management.
An FDA pivotal trial included 64 patients where one eye was randomized to receive the negative pressure treatment and the contralateral eye did not (control). Patients remained on medications. At 3 months, IOP was reduced to 12.9 mm Hg, on average, from an average baseline of 19.4 mm Hg. The average IOP in control eyes at the end of the study was 18.4 mm Hg (baseline 19.1 mm Hg). Nearly 90% of study eyes met the primary endpoint of 20% IOP reduction from baseline.
Editors’ note: The physicians have financial interests with several ophthalmic companies.
Addressing a range of presbyopia treatment topics
A symposium featured several quick-hit presentations on a variety of topics related to treatment of presbyopia, culminating in the Barraquer Lecture.
The lecture was given by Graham Barrett, MD. He gave a brief history of the pioneering work of Jose Barraquer, MD, and said that the ideal refractive procedure would be safe, predictable, and reversible. Dr. Barrett focused his lecture on the potential ways to reverse the impact of refractive surgery prior to cataract surgery.
Additive refractive procedures, such as inlays or epikeratophakia, can be reversed with tissue or implant removal prior to cataract surgery, Dr. Barrett said. Subtractive refractive procedures, like laser vision correction, cannot be so easily reversed, but Dr. Barrett described how appropriate formulas can adequately account for the prior refractive surgery in IOL power selection. He discussed use of his Barrett True K and Barrett True K TK formulas and shared several studies that have found these formulas to be more accurate for post-refractive patients and keratoconic patients.
Outside of the named lecture, Sonia Yoo, MD, presented on how to address the unhappy premium IOL patient. The majority of these patients, she said, are unhappy due to a residual refractive error. Dr. Yoo said it’s important to first look at the patient’s uncorrected distance, intermediate, and near vision and refract the patient to see if it can be solved with glasses, contact lenses, or laser vision correction.
If it can’t, next Dr. Yoo said to look at OSD and treat what might be affecting visual quality. Other postop conditions, such as CME, should be diagnosed and treated early. If a patient is happy with their vision initially then it gradually decreases, Dr. Yoo said to suspect PCO. Preoperatively, she stressed finding pre-existing conditions that might preclude a patient from being a candidate for a premium IOL, such as epiretinal membrane or keratoconus.
Editors’ note: Dr. Barrett has financial interests with several ophthalmic companies. Dr. Yoo does not have financial interests related to her comments.
Castroviejo Lecture
This year, Carol Karp, MD, delivered the Castroviejo Lecture on how high-resolution imaging has changed her practice of ocular surface oncology.
Dr. Karp first shared a case of a 79-year-old male referred for dry eye and blurred vision. He had a history of lid surgery in the past, was on topical glaucoma medication, and had had skin cancer. His vision was 20/150, and he had dense epithelial irregularities and MGD.
Dr. Karp was having trouble seeing what was really going on at the slit lamp. But she said that high-resolution OCT is her “super power” and can help tell her what she’s seeing.
This patient had thickened hyperreflective epithelium with abrupt transition, which indicated OSSN.
Dr. Karp noted that she often uses biopsy to help as well, and she said that OCT helped direct her where to biopsy.
She also shared steps to diagnose an OSSN on OCT. She noted that it’s important to first find normal epithelium. Then, find the inferior edge of the epithelium. Assess the main lesion, Dr. Karp said. Is it epithelial or subepithelial? Is it thickened, hyperreflective epithelium? Finally, she said to look if there is an abrupt transition from normal to abnormal epithelium.
Dr. Karp shared photos from a variety of other cases that she was evaluating. In one, the OCT had a subepithelial lesion with hyperreflectivity, and the epithelium was thin and normal. This was not OSSN, but it was Salzmann’s.
Another patient was referred for OSSN, but the OCT showed normal epithelium, and there was a subepithelial hyperreflective mass. This was a melanoma.
Another case, which turned out to be conjunctival lymphoma, showed odd pinguecula with monomorphic dot-like infiltrates.
A 69-year-old was referred with conjunctival melanoma, and the OCT showed normal epithelium and thickened hyperreflective epithelium and abrupt transition, so Dr. Karp noted that this was actually pigmented OSSN.
Circling back to the first patient she mentioned with OSSN, Dr. Karp said she treated the patient with 5 FU 1% QID for four cycles. The OCT normalized, and repeated biopsies confirmed resolution.
What about surgical removal of tumors? Dr. Karp said it’s important to be sure the margins are clear. The chance of recurrence is much higher if leaving residual disease, she said.
Dr. Karp added that she hopes high-resolution OCT will soon be available to integrate into operating microscopes.
Dr. Karp also noted that there are some limitations of high-resolution OCT. If you don’t image the area of interest, it’s not helpful, she said. You need to take many cuts around the lesion and everywhere to not miss anything, she said, adding that she and her fellows draw the location of interest before imaging. Train your imagers, and get them excited about their role, she said.
Editors’ note: Dr. Karp has no related financial interests.
Cornea debates
Anthony Aldave, MD, chaired the “The Great Debate: Cornea” symposium, which explored a number of topics within the cornea subspecialty, with experts sharing different views and audience members voting on which side of the issue they agreed with (with audience being polled before and after the arguments were presented).
One debate during the session was between artificial intelligence (AI) and experienced clinicians in the diagnosis of keratoconus and infectious keratitis.
Maria Woodward, MD, argued that AI will replace the clinician in the next 10 years, while Stephen Klyce, PhD, argued that it wouldn’t. Ahead of the presentations, 24% of the audience said they believe AI will replace the clinician in the next 10 years, while 76% said they do not think AI will replace the clinician in the next 10 years.
Dr. Woodward started by defining “what is a clinician.” A clinician is someone who triages, diagnoses, and manages disease, she said. The clinician should listen, communicate, and care for the sick.
She then discussed if clinicians today are effectively diagnosing and managing ulcers. Cultures are negative around 50% of the time, she said. How often are you certain what to do next? But with AI, Dr. Woodward said there are algorithms that can distinguish between organism categories.
The same question can be asked for keratoconus, she said. There is a lot of good evidence that AI algorithms can distinguish between keratoconus types and who should get crosslinking or transplantation.
Dr. Woodward then went on to discuss if today’s clinicians are compassionate and treat patients well. There’s plenty of evidence about how we could be delivering better care if we’re compassionate, she said. The real issue is the quality of care we’re delivering is subpar for our patients without technology, and the quality of relationships is subpar because technology is coming up against us.
Today’s clinicians, Dr. Woodward said, provide less than ideal care for patients, and she thinks “we all know we can do better.” Technology is not the enemy, she said, adding that she thinks that technology-aided care will replace today’s clinicians.
On the other side of the argument, Dr. Klyce argued that AI will not replace clinicians in the next 10 years. He thinks AI really is the future of healthcare, and he said that the first true AI in ophthalmology was published in the 1990s. However, when used to help with keratoconus, corneal topography is insufficient by itself to make a diagnosis. It’s interpretation, but not a diagnosis.
Dr. Klyce argued that AI is only as good as the data used for training. The clinician has access to many sources of data beyond the scope available to AI, and AI needs constant revision as technology advances. Even with expert consensus, there will be bias, he said, concluding that AI will not replace the clinician but will continue to provide access to new tools to aid in clinical diagnosis.
After the presentations concluded, 28% of the audience said they think AI will replace the clinician in the next 10 years, while 73% said they do not think AI will replace the clinician in the next 10 years.
Editors’ note: Dr. Woodward and Dr. Klyce have financial interests with several ophthalmic companies.
Ophthalmic Premier League
Presenters in the Ophthalmic Premier League session shared various videos of complications they’ve experienced.
During his presentation, Naveen Rao, MD, described the IOL scaffold technique after posterior capsule rupture.
His case involved a 70-year-old man with a dense, traumatic cataract. During the procedure, Dr. Rao was struggling making the groove, and the nucleus was very dense. The patient had zonular weakness and a leathery posterior plate, and the phaco tip was not able to get deep enough into the groove to crack it, Dr. Rao said, adding that this led him to switch techniques.
He saw a bright red reflex that led him to believe that a nuclear piece was migrating subincisionally. Dr. Rao used viscoelastic to elevate the nuclear pieces. He noticed a large PC tear, but the rhexis was intact.
Dr. Rao said he had a few choices for what to do next. He could have elevated the pieces to the AC and removed with a lens loop, but he worried about pulling a lot of vitreous. Dr. Rao also could have left the pieces in the sulcus and done anterior vitrectomy, but he worried about decompressing vitreous.
Ultimately, he chose to do the IOL scaffold technique. This involves elevating the pieces of nucleus into the AC first, then performing anterior vitrectomy, placing a 3-piece IOL in the sulcus or above the iris, using phaco for the remaining nuclear pieces, and depositing the haptics in the sulcus (optic capture). The IOL acts as a scaffold in this technique, he said.
Dr. Rao noted that there are many applications for the IOL scaffold technique, including to prevent dropping nuclear fragments after PC tear, to prevent losing Soemmering’s ring pieces during scleral fixation of IOLs, and to prevent PC tear while cutting the IOL during bag-to-bag IOL exchange.
Editors’ note: Dr. Rao has no related financial interests.
The role of anterior segment imaging highlighted in symposium
Charles Lin, MD, shared how slit lamp photos can tell you more than you think. His presentation highlighted machine learning applications that can be applied in medicine. It can assist with diagnosis and management algorithms. Ophthalmology has been at the forefront of machine learning applications, Dr. Lin added. He also discussed what AI models are looking at and specific techniques and models. He shared several photos and asked audience members to try to differentiate between what was being shown.
Dr. Lin spoke about some of the characteristics of fungal keratitis and bacterial keratitis. With fungal keratitis, Dr. Lin first mentioned filamentous fungi, which have a feathery margin, a dry, rough texture, elevated edges, satellite lesion, endothelial plaque, and pigmentation. Meanwhile, for candida, this has oval ulceration and more demarcated dense suppuration.
In terms of bacterial keratitis, Dr. Lin broke it down among Pseudomonas, Staphylococcus aureus, and Streptococcus pneumoniae. Pseudomonas is classified by severe suppuration, ring infiltrate, keratolysis, and perforation. Staphylococcus aureus is classified by multifocal round lesions, distinct borders, dense infiltrates, and endothelial plaque. Streptococcus pneumoniae is classified by acute, purulent, rapidly progressive, deep stromal abscess, retro-corneal fibrin, and hypopyon.
Dr. Lin concluded by saying that convolutional neural networks demonstrate promise in differentiating scar vs. ulcer and bacterial vs. fungal. Accuracy is comparable or even better than human experts, he said, but there is significant work to be done before real-world implementation.
Editors’ note: Dr. Lin has no related financial interests.
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