- ‘What I’m doing in 2024’
- ‘What I wish I’d known the first 5 years’
- Cornea and glaucoma
- Glaucoma special lecture
- ‘Sizzle or Fizzle’
Programming at the American Academy of Ophthalmology (AAO) Annual Meeting on Friday covered a variety of topics, with a focus on refractive and glaucoma.
‘What I’m doing in 2024’
Audrey Rostov, MD, discussed how she’s using lenticule extraction and corneal refractive surgery. Patients want great outcomes and safe procedures, she said, adding that you can get great outcomes with LASIK, SMILE, and PRK.
What’s new with SMILE? Dr. Rostov noted shorter treatment times (10 seconds). She also said there is ocular alignment for improved astigmatism treatment (she mentioned CentraLign, which helps with centration, and OcuLign, which helps with computer-assisted pattern rotation for cyclotorsion alignment).
Dr. Rostov went through SMILE step by step, as a series of lamellar resections:
- The first lamellar cut defines the posterior surface of lenticule.
- The first side cut defines the lenticule diameter.
- The second lamellar cut defines the anterior surface of the lenticule/posterior surface of the attached cap.
- The second side cut creates an incision for removal of the lenticule.
Why SMILE? Dr. Rostov noted the major benefits of less dry eye and no flap. “When a patient of mine is an equal candidate for any of the laser vision correction procedures, I tend to favor SMILE,” she said.
Dr. Rostov also discussed improvements with the VisuMax 800 (Carl Zeiss Meditec) compared to the previous VisuMax 500 platform. There is less cut time, and the overall surgical time is cut by a third. The main hardware difference is the driving of the femtosecond laser head at an increase pulse frequency of 2,000 kHz; this has reduced the SMILE lenticule delineation time from approximately 30 second to less than 10 seconds. Speed matters because it’s more comfortable for the patient and surgeon, and you’ll decrease suction breaks and suction losses, she said.
Mitchell Weikert, MD, discussed adjustable IOLs, including available products and those in development. Why do we need adjustable IOLs? Dr. Weikert said surgeons are hitting around 74% of outcomes within ±0.5 D of target, and you can increase this using advanced formulas. But there are still things to improve.
The Light Adjustable Lens (RxSight) is the currently available technology that allows surgeons to adjust the IOL power for patients after implantation. This includes additional treatments and lock-ins in the postop period after the lens is implanted. Dr. Weikert noted that timing of these additional treatments varies on the patient, particularly if the patient has had previous surgery.
He said there are a lot of exciting options on the horizon. Refractive index shaping uses the femtosecond laser to alter the refractive index of the IOL material. This increases hydrophilicity, and you can use it to change the refractive power.
There are also some modular IOLs/accommodating IOLs in the pipeline. Dr. Weikert mentioned the Gemini refractive capsule (Omega Ophthalmics) and the fixOflex (EyePCR). These are both rings made of silicone that you can implant in the capsule. There’s a ridge when you inject the IOL, and you can fixate the IOL into the ring. There two options are agnostic, so you can use any lens.
Dr. Weikert also mentioned two accommodating IOLs in development, the Juvene (LensGen) and the OmniVu (Atia Vision). With the Juvene, you inject the base lens, which is a single monofocal optic, then you inject a second lens that docks in that ring, and this lens is accommodating. With the OmniVu, the first lens that goes in is the adjustable, liquid-filled lens, then a monofocal goes on top of that.
Editors’ note: Dr. Rostov has financial interest with Alcon, Bausch + Lomb, and Carl Zeiss Meditec. Dr. Weikert has financial interest with Alcon, Carl Zeiss Meditec, and Epion Therapeutics.
‘What I wish I’d known the first 5 years’
During this session, Edmund Tsui, MD, discussed social media and the value this can have for a practice. Dr. Tsui discussed his changing mindset about social media, noting that a few years ago, he saw it more as a platform for vacation photos, but now he knows it’s an essential tool for ophthalmologists and trainees. Some of the benefits of social media are patient education and reach, networking and collaboration, and building trust and reputation.
How do you get started on social media? Dr. Tsui showed his own profiles on several platforms, noting that he uses the same presence and branding across platforms to help with credibility and recognition. He also shared some do’s and don’ts of social media.
Do: Share educational content, respect patient privacy, engage with your audience, use high-quality visuals, and be authentic.
Don’t: Share misleading or exaggerated results, neglect your profile or posts, engage in arguments or unprofessional discussions, post too much “salesy” content, or overlook copyright issues.
Dr. Tsui concluded by sharing some practical tips for success with social media, including choosing the right platform for your goals (he recommended starting with one or two platforms), sharing success stories (with patient consent), posting educational content regularly (aim to post 2–3 times per week with a mix of images, infographics, and videos), engaging with other professionals, and using hashtags and location tags (which allow for easier search and increased visibility).
Editors’ note: Dr. Tsui has no relevant financial interests.
Cornea and glaucoma
In a glaucoma session reviewing what other specialties can teach, Jeffrey Ma, MD, discussed how glaucoma specialists create problems for cornea specialists and vice versa. He shared several case examples.
His first case was that of a 74-year-old man with mixed mechanism glaucoma who reported slowly worsening vision in the right eye. He had a tube shunt in place.
Dr. Ma noted that the patient had cornea edema and that corneal edema is one of the most common complications after glaucoma surgery. He said it’s also the most common late cause of reoperation or loss of vision. Risk factors for developing corneal edema include advanced age, preexisting corneal pathology, or postop factors (hypotony, tube-cornea touch, flat chamber, tube revision, or infection). Potential causes of corneal edema could be mechanical trauma, inflammation, or fluid turbulence, Dr. Ma said.
Dr. Ma said that EK is the surgery of choice for a decompensated cornea. EK can cause a hyperopic shift because it’s altering posterior curvature of the cornea. He said to avoid YAG capsulotomy if EK may be needed in the near future.
In his second case, Dr. Ma discussed a 49-year-old woman with Peters anomaly in the right eye and congenital glaucoma. She had recurrent episodes of severe pain in the right eye after tube shunt surgery and had had hand motion vision in that eye since childhood. This patient had bullous keratopathy, and she had minimal improvement with hypertonic saline. Dr. Ma noted that EK is a potential option, but it’s a very low visual potential in the eye. He said that anterior stromal puncture was offered, which is an effective treatment for bullous keratopathy and avoids EK, which could worsen glaucoma.
Dr. Ma went on to discuss when glaucoma may pop up after a cornea procedure, sharing a case of a 55-year-old man with Acanthamoeba keratitis who had a perforated cornea after rubbing the eye. A therapeutic PKP was done, and Dr. Ma said the cornea looked great at 1 month, but the IOP was very high.
He noted risk factors for developing glaucoma, including the indication for a transplant, higher IOP preoperatively, and larger PKP donor graft size. Some of the causes of glaucoma after corneal transplant include steroid response, pupillary block from gas bubble, formation of PAS and iridocorneal adhesions, inflammatory debris obstructing the trabecular meshwork, and difficulty in measuring IOP.
Dr. Ma last spoke about a patient referred from the glaucoma service for ocular surface disease (OSD) management, and upon the diagnosis of glaucoma, instead of putting her on glaucoma drops, they offered SLT as the initial treatment. In patients with challenging OSD, remember there are more and more therapies to help optimize the ocular surface, he said.
Dr. Ma’s take-home points were that corneal decompensation can occur after glaucoma surgery; surgical management of corneal decompensation can worsen glaucoma; and comanagement between glaucoma and cornea specialists is critical.
Editors’ note: Dr. Ma has no relevant financial interests.
Glaucoma special lecture
Pradeep Ramulu, MD, PhD, gave a special lecture on the topic of “The Unknowable Truths of Glaucoma: Dealing with Uncertainty in Clinical Practice.”
One of the things he discussed was the issue of “overtreatment,” and he noted some of the drivers of overdiagnosis and overtreatment in general medicine and specifically glaucoma, including uncertainty in diagnosis, testing/imaging, efficacy of therapy, and the impact of diseases on the individual. One approach to dealing with clinical uncertainty is to broadly apply a safe, proactive approach to care.
There is evidence that the interventional approach is in line with patient desires, Dr. Ramulu said. Patients want a lot of screening and testing because they want to catch things early, but they don’t want overtreatment with medications, he said.
So why not give patients what they want, even if it means overtreating some patients? He said that medical overtreatment can create a considerable societal burden. He went on to discuss how physicians are becoming a “scarce resource” as the patients in need of ophthalmic care grow. Already there’s a shortage of care, especially glaucoma care, in rural settings, he said, adding that this will worsen in the future, and it could also worsen in metropolitan areas.
In glaucoma, it’s easier to deal with uncertainty, Dr. Ramulu said because glaucoma has a continuous outcome. OCT has made it so we can catch disease early.
The goal is to help us better understand and deal with uncertainty in glaucoma—understanding the level of uncertainty in measurements and learning when uncertainty can be tolerated (when it can be watched versus when it should trigger an interventional mindset), or when to get more intensive testing to decide between the two.
Discussing diagnosing glaucoma and starting treatment, Dr. Ramulu said there is no evidence for functional impairment in pre-perimetric glaucoma. Early unilateral visual field damage is functionally relevant, but the impact is mild. He went on to discuss IOP and other factors in glaucoma treatment.
Editors’ note: Dr. Ramulu has financial interests with Alcon, Dompe, the National Institute of Health, Perfuse Therapeutics, Topcon Medical Systems, and WL Gore Inc.
‘Sizzle or Fizzle’
In an afternoon refractive section, presenters shared several technologies and tools, and audience members voted on their potential and if they thought these ideas would “sizzle or fizzle.”
Emily Schehlein, MD, presented on GreenMan, which audience members voted as “sizzle.” This is a virtual reality software that works on a virtual reality headset and allows patients to test drive IOL options prior to cataract surgery. This uses the patient’s own refraction and biometry to test options so we’re all on the same page with no surprises, she said. Patients can visualize their vision options with different IOLs in different settings, including in a dimly lit environment to see glare and halos. Dr. Schehlein said there are no regulatory barriers to using this program, so you can get it to patients as soon as possible.
Editors’ note: Dr. Schehlein has financial interests with Alcon, Allergan, Glaukos, MicroSurgical Technology, and Perceptron Health.
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