- Steinert Refractive Lecture highlights refractive cataract surgery
- Digital Day keynote: tapping extended reality to improve healthcare
- Complicated video cases showcased at Glaucoma Day
- Obstbaum Lecture focuses on interventional glaucoma
- Additional sessions
Steinert Refractive Lecture highlights refractive cataract surgery
The Steinert Refractive Lecture closed out ASCRS Refractive Day. This year, Vance Thompson, MD, delivered the lecture on the topic of “Refractive Cataract Surgery: Under Pressure.” Cathleen McCabe, MD, introduced the lecture, noting that the Steinert Refractive Lecture is named after Roger Steinert, MD, who was an innovator, researcher, and driver of refractive surgery. Dr. Thompson is all of those things as well, she said. Dr. Thompson began his lecture by discussing his history with Dr. Steinert and how they worked together throughout his career.
“I think of myself as a physician who is an ophthalmologist and at his core is a refractive surgeon,” he said. I think we’re thinking about uncorrected and best corrected visual acuity but ultimately also need to be thinking about where we’re leaving the patient’s uncorrected and best-corrected image quality. I know, if I’m a patient, I want to be able to see well and crisply, he said.
He highlighted his research journey and discussed his work with phakic IOLs, presbyopia-correcting technology, and more. He realized the refractive surgery was moving towards the lens and wanted to think about how to become a comprehensive refractive surgeon.
Dr. Thompson also discussed his participation in clinical trials for trifocal lenses. He remembered 99.2% of patients in a trifocal study said they would choose that option again and would recommend it. The Light Adjustable Lens (RxSight) was another trial that Dr. Thompson noted his involvement in.
I want to thank industry for what they’ve done for research and development and to bring the diagnostics and implants and help us create what we call premium cataract surgery, he said.
Dr. Thompson discussed the pressures holding back premium cataract practices, and particularly getting involved with presbyopia-correcting technology. I think the pressure is surgeon confidence, he said, noting the need to teach new users to get involved in new technologies.
The most powerful thing that has led to growth of our seven centers in upper Midwest is how we love and care for each other and our patients, he said. “I teach whole-day courses on how to create a team culture.” This culture is important for the premium cataract surgeon.
Surgeon confidence needs to include an understanding of dysphotopsias, Dr. Thompson said. You can measure and evaluate a number of other factors as well, he said, mentioning the tear film, epithelium, anterior stroma, IOLs, posterior capsule, and the vitreous.
We have old technologies and tests that can still help us, Dr. Thompson said, stressing the importance of a gas permeable lens over refraction. Besides optimizing in the clinic, we need to optimize in the surgery, he said.
Dr. Thompson went on to touch on the use of the femtosecond laser. “I’m a big believer in the automated capsulotomy,” Dr. Thompson said, but he said he wasn’t going to debate about what’s better between manual, femtosecond laser, or Zepto (Centricity Vision). He mentioned a study that measured patient satisfaction and induction of internal comma. He noted a study on refractive outcomes where there was no difference between femtosecond laser and traditional cataract surgery, but Dr. Thompson thinks there are other ways to “peel back the onion.” We must look at things like capsular overlap rate and induced HOAs, he said.
As we minimize other sources of aberrations and we really want the patient to neuroadapt beautifully, we want to remember the power of neuroadaptation, he said. If you can think of it as a one-year journey, you will be happy, he said. Even though I tell them all about the one-year journey, he said, I also have our team call them at one month. There are a lot of patient personalities, and they don’t always remember what you told them in the clinic.
“What I present is a recipe to realize that what we can do with presbyopia implants is amazing,” Dr. Thompson said.
Editors’ note: Dr. Thompson has financial interests with a variety of ophthalmic companies.
Digital Day keynote: tapping extended reality to improve healthcare
David Rhew, MD, global chief medical officer and vice president of healthcare for Microsoft, delivered a keynote address about extended reality in healthcare during Digital Day, sponsored by the Digital Ophthalmic Society (DOS) alongside ASCRS Subspecialty Day programs.
Extended reality, he said, encompasses augmented reality, mixed reality, and virtual reality. And it has the potential to help improve healthcare outcomes, access to care, health safety, and efficiency of care.
Extended reality technology has already been demonstrated to be effective and useful in the area of ophthalmology, Dr. Rhew said. It’s being used in education/training, surgical assistance, diagnosis/screening, and low-vision services.
In education and training, Dr. Rhew said that students who used the HoloAnatomy application with the HoloLens 2 demonstrated a 50% higher retention rate of information being delivered with 40% less class time. Dr. Rhew also presented how Case Western Reserve University brought HoloLens 2 with HoloAnatomy in for virtual instruction experiences during the COVID-19 pandemic.
“When we think about how we train individuals, this is a proven way to do it,” he said, also showing how the University of Michigan is using this technology to not only educate about anatomy and structures but also about procedures. Dr. Rhew said extended reality has utility in research collaboration and surgical planning. He showed an example where doctors who were all thousands of miles apart were virtually gathered around a 3D rendering of a brain to map out a complex surgery. The doctors were able to do this despite the distance but also in less time than it would have taken without the virtual technology.
“We’re starting down that path in ophthalmology where we have the opportunity to collaborate in ways that we could not have,” Dr. Rhew said. “Imagine being able to take images of that individual and have individuals collaborate presurgical planning.”
The technology is not just for presurgical planning. Dr. Rhew said the technologies can be used to democratize learning across a range of skill levels and experiences.
Dr. Rhew said that extended reality can help the stretched ophthalmic workforce. There are so many things placed on ophthalmologists that are very time consuming, such as diabetic retinopathy screening. Dr. Rhew said capture mechanisms and AI applications meeting patients where they are can alleviate some of the burden on ophthalmologists so they can focus on what they’re uniquely good at.
From a low-vision services standpoint, Dr. Rhew shared a video of a Microsoft engineer who had been blind since age 7 and, as an adult, helped develop an app that “tells you at any moment what’s going on around you.” The app runs on smartphones and smart glasses. It can help people read text, like menus for example, and recognize what people around them are doing. The engineer said the app can describe the general age, gender, and emotions of people.
“Where we want to go now is toward scalability,” Dr. Rhew said. While this technology in education and training is at academic medical centers now, they’re looking toward bringing it into the metaverse. Where the technology for surgical assistance is currently being used for complicated cases, it could be used to democratize specialty care. Diagnosis/screening with these types of technologies is currently in pilot phases, but Dr. Rhew said the hope is for it to expand access to care. And finally, low-vision aids using extended reality are also in pilots, but the hope is that it will someday be used on a broader scale to improve the quality of life for all low vision patients.
Editors’ note: Dr. Rhew has financial interests with Microsoft.
Complicated video cases showcased at Glaucoma Day
ASCRS Glaucoma Day concluded with the 13th Annual Video Session: Complications and Reay of Hope. “This is where all of you get to choose the gnarliest, best, ugliest, video of the year. Thank you to our brave souls who are bearing it all for you,” session moderator Manjool Shah, MD, said.
The winning video was presented by Ari Leshno, MD, and Aakriti Shukla, MD, as a fellow/attending team. The case was called “A Hole in One.” They showed a 56-year-old with moderate JOAG who was referred with an IOP of 46 mm Hg, on maximum medical therapy, and prior surgical interventions.
They decided to pursue trabeculectomy. They described how during flap creation an area of weakness was observed on the right side of the flap. They continued placing sutures, and at one point, the stay suture detached. They replaced this suture, made multiple needle passes through the flap, and then entered the AC. They then noticed a leak on the left side of the flap, so they put a suture there. Then there was a leak on the right side of the flap, so they sutured again. Then there was a gush of fluid from the central flap, showing a hole that they speculated could have been made from multiple needle passes and stretching of the flap. They used a graft to remedy the problem, trimmed the flap, closed the perimetry, and ended up with a water-tight, sealed, elevated bleb, and a deep AC.
Leon Herndon Jr., MD, presented a video titled “Save the Implant: Transected Baerveldt Tube.” The patient was a 73-year-old male who was pseudophakic, had severe pseudoexfoliation glaucoma, and a history of trabeculectomy, endoscopic cyclophotocoagulation, and XEN Gel Stent (Allergan) in the right eye. Despite these interventions the patient had persistently high IOP (27 mm Hg on max medical therapy), and his care team decided to place a Baerveldt drainage device (Johnson & Johnson Vision). The patient’s XEN was also removed.
Once in the OR, under general anesthesia at the patient’s request, as the Baerveldt was being prepared, the tube was transected with a Vicryl suture and fell off the surgical field. While opening a new implant would be a reasonable option, Dr. Herndon said, there was not another one available in the ASC where he was operating, and a new implant would have been expensive. So, he was forced to salvage the implant. The questions were: Is it doable? Is there an alternative tube if the main tube fell off? How to connect the tubes?
“What if we can marry the Crawford tube with the Baerveldt tube and save this device? Here comes the Herndon tube stretching forceps,” Dr. Herndon said, demonstrating this technique that connected the two tubes followed by completing the case normally.
At postop day 1, Dr. Herndon said the patient was doing well with a stable tube visible in the sulcus and an IOP of 8 mm Hg. At 6 months, the tube was still stable with an elevated and vascular bleb and an IOP of 10 mm Hg. At this point the patient was on dorzolamide timolol BID and latanoprost each night.
In the presentation, Dr. Herndon described the Herndon Tube Stretching forceps (Epsilon) and briefly shared another case like this that confirmed tube durability over time. Dr. Herndon also said that this technique of saving the implant is more cost effective than complete replacement.
Ang Li, MD, presented a video that showed a transcorneal tube tie off for chronic hypotony due to exposed ripcord. Mary Qiu, MD, shared a video involving a 78-year-old patient with severe POAG. This patient was pseudophakic in both eyes with a Baerveldt-350 in her right eye and a failed EX-PRESS shunt (Novartis) in her left. Dr. Qiu’s video showed GATT performed in this eye. She had difficulty pulling the GATT through a couple of times but let go in those instances and ultimately was able to complete a 359-degree trabeculotomy.
Editors’ note: Dr. Herndon, Dr. Li, and Dr. Qiu do not have financial interests related to his comments.
Obstbaum Lecture focuses on interventional glaucoma
Ike Ahmed, MD, in delivering the Stephen A. Obstbaum, MD, Honored Lecture at Glaucoma Day, spoke on the technology paradigm shift that is interventional glaucoma.
Dr. Ahmed said that the 2000s are when MIGS were met with ridicule, questions, and controversy. He acknowledged, MIGS is not perfect for everything, but the concept of MIGS is now clear. Here in the 2020s, he said the subspecialty is faced with another major change: the concept of interventional glaucoma.
“We are at a point in time where we’re seeing significant shifts in how we treat glaucoma and in our treatment paradigm,” he said. Dr. Ahmed said we need to change the way we model things because our models don’t work. He explained that he would argue the field is ready for a new approach to initial and stepwise interventional glaucoma therapy.
The current paradigm is very medication heavy, with a period of watching and waiting for progression. SLT, he noted, is mostly considered after maximum medical therapy and surgery is reserved for refractory glaucoma. The problems with this current paradigm are issues with patient compliance/adherence, suboptimal 24/7 IOP control, and histopathological changes that could be linked to medication and progression that are leading to irreversible damage that further impacts therapy efficacy. Dr. Ahmed said it’s time to take treatment out of the patient’s hands and provide 24/7, sustained therapy to control IOP, prevent progression, and improve quality of life.
Dr. Ahmed sees this being done with a new paradigm that puts SLT as a first-line therapy, improved drug delivery options, non-incisional MIGS, standalone MIGS, a continued use of combined MIGS and phaco, and microinvasive bleb surgery. He acknowledged that the right patient for the right procedure at the right time is still important.
“For me, interventional glaucoma is addressing that earlier patient who doesn’t need aggressive therapy but isn’t best served by medical therapy. Glaucoma is only young once … as it gets older, it’s harder to treat,” Dr. Ahmed said.
He went on to describe interventional glaucoma (or IG) as an attitude. It’s one that is proactive vs. reactive. It relies on early predictive diagnostics, active and advanced monitoring, and early intervention that might be more aggressive, and it addresses adherence and risk. What he means by a proactive approach is not waiting for disease progression, avoiding medication stacking, and knowing when it’s time to intervene. For predictive diagnostics, he said there could be risk-factor analysis, ocular biomechanics, genetic testing, digital health, and the use of AI. Advanced monitoring could include structural and functional progression analytics, home monitoring, IOP sensors, and detecting apoptosing retinal cells.
“The concept is to try to do things earlier. … The impact on the patient’s lifetime is greater when we apply them earlier in the disease process,” he said, but Dr. Ahmed noted that the issues associated with surgery—lack of predictability and increased complication risk—need to be avoided. This is where he thinks invasiveness matters. “Less invasive options have advantages and disadvantages, but it’s about our ability to address disadvantages.”
He posited that the interventional glaucoma treatment algorithm would go from SLT to sustained drug delivery to one or two MIGS to microinvasive bleb surgery to trabeculectomy or tube. Dr. Ahmed discussed the options and data within each of these categories. Medication, he envisioned, would become bridges as the treatment went from one intervention to the next. Medications and trabeculectomy, Dr. Ahmed said later, are still important.
When it comes to moving the subspecialty toward a mindset of interventional glaucoma, Dr. Ahmed acknowledged barriers. These include our attitude, clinical evidence, access/cost, practice workflow considerations, and others.
Editors’ note: Dr. Ahmed has financial interests with various ophthalmic companies.
Additional sessions
The Friday ASCRS Main Stage session featured the official kick off of the ASCRS Annual Meeting, with leadership and special award recognitions.
ASCRS Cornea Day sessions covered topics in cell therapy and a variety of office-based disease management and surgical cases.
For further coverage of ASCRS Subspecialty Day and Annual Meeting events, see the Saturday edition of the EyeWorld Daily News.
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