Friday programming ahead of the official kickoff of the 2021 ASCRS Annual Meeting featured three Subspecialty Day programs on refractive, glaucoma, and cornea.
Marguerite McDonald, MD, delivers Steinert Refractive Lecture
Marguerite McDonald, MD, gave the Steinert Refractive Lecture at ASCRS Refractive Day, describing it as a pleasure to be selected to honor “this brilliant clinician-scientist,” Roger Steinert, MD. Her talk focused on the current and future treatments of presbyopia for phakic patients.
Current solutions include glasses, contact lenses, and surgery. Multifocal glasses, Dr. McDonald described, are associated with an increased risk of falls. In elderly patients, she continued, more than one in three falls can be attributed to multifocal glasses.
Contact lenses for presbyopia are underutilized, among contact lens wearers, and have a low retention rate. Dr. McDonald presented data that showed only 46% of presbyopic contact lens wearers are offered multifocal or monovision options, and research has shown only about 50% retention for patients who have tried these types of contact lenses.
Surgical solutions like monovision LASIK, SMILE, and PRK have achieved some popularity, especially among former contact lens wearers who have tried monovision, Dr. McDonald said. But she noted some of the drawbacks to monovision include its association with a decrease in intermediate and mesopic visual acuity and its effect on contrast sensitivity and stereoacuity. PresbyLASIK, she said, has not yet become popular due to the induction of blur from increased aberrations with loss of contrast sensitivity. Dr. McDonald noted that subsequent modifications to the technique claim to overcome these limitations.
Dr. McDonald also described laser thermokeratoplasty and conductive keratoplasty, both of which are FDA approved, but neither have achieved widespread adoption. Optimal keratoplasty (Opti-K), which has the CE mark, uses an infrared thulium fiber laser-based system; it is in clinical trials for hyperopia and monovision treatments in the U.S. Dr. McDonald described Opti-K as a noninvasive, rapid procedure with minimal discomfort and downtime. She said it is safely repeatable, as needed, because the treatment regresses completely over 1–2 years.
Next, Dr. McDonald moved into what’s on the horizon, first addressing the multitude of presbyopia-correcting drops in clinical trials. Many of these work with pupil-constricting agents, such as pilocarpine. She noted that pilocarpine in these trials is much lower than what was used in glaucoma and is being delivered with sophisticated vehicles. She also discussed companies working on lens softening agents.
Dr. McDonald closed talking about LIRIC (laser-induced refractive index change). This investigational treatment is produced by a femtosecond laser to noninvasively alter the refractive index of the cornea. She described it as a minimally invasive treatment with almost no effect on corneal nerves that wouldn’t need antibiotics or steroids. She said this technology could also be used to induce multifocality on monovision IOLs (or vice versa) and in contact lens technology.
Editors’ note: Dr. McDonald has financial interests with several ophthalmic companies.
Panel shares their proudest career moments in Obstbaum lecture
The Stephen A. Obstbaum, MD, Honored Lecture took on a different format this year. Past leadership from the ASCRS Glaucoma Clinical Committee—Reay Brown, MD, Richard Lewis, MD, Thomas Samuelson, MD, and Douglas Rhee, MD—and moderator Leon Herndon, MD, current chair of the Glaucoma Clinical Committee, took to the stage to share an aspect of their career that they’re most proud of.
Dr. Brown spoke about the many procedures and devices he was involved in researching. The one he said he is most proud of is EyePass, which he described as the first trabecular bypass device. He worked on this device from 1999–2006, went through three FDA studies, but ran out of financing and was ultimately not successful with it. However, this work led to some of the fundamental paths and understanding of trabecular bypass.
Dr. Lewis focused his presentation on changes in canaloplasty. Canal surgery is not new, he said, noting that it’s been going on for 60 years, giving a history of canal surgery milestones and its clinical milestones. Early on, Dr. Lewis said canaloplasty met resistance within the subspecialty, but it persevered as a procedure.
“We had a few early adopters but a lot of negative feedback. The key was the catheter but also the beacon of light because it told you where you were. … In the process of canaloplasty, you viscodilate the canal but also tension the trabecular meshwork,” Dr. Lewis said, noting how the latter was impactful for the procedure’s efficacy.
Dr. Lewis said that early comparative studies between trabeculectomy and canaloplasty showed impressive results in canaloplasty’s favor, with pressure that remained for at least a year. A similar sustained IOP reduction can’t be said for many modern MIGS procedures, Dr. Lewis said.
Dr. Samuelson shared how he has been “honored to have been ‘in the room where it happens.’” For much of his career, he said, he had patients who were miserable from bleb leaks, infections, toxicity from drops, and more.
“It took a lot of us to call out trabeculectomy for being too invasive, too risky for mild to moderate disease. I’ll grant that trab is a great opportunity for those with severe vision loss, but I think the MIGS mindset changed everything,” he said. “It’s the mindset that safety is as important as efficacy that has changed the management of glaucoma forever.”
One of the things that allowed this to happen was research that showed cataract surgery is helpful in the management of glaucoma. He also said he was proud to be the FDA panel presenter for iStent (Glaukos). This device “launched a whole new mindset in the management of glaucoma,” Dr. Samuelson said.
He went on to speak about his involvement in the development of what’s now the Hydrus Microstent (Ivantis).
Dr. Rhee said one of the things he is most proud of is the discovery of SPARC, a protein that is a critical regulator of outflow resistance.
Prior to this discovery, little was known about how outflow was regulated. With that, all treatments were not disease modifying, rather palliative, not addressing what’s actually causing glaucoma, Dr. Rhee said. Through exploration and research, Dr. Rhee described how he and others worked out a lot of the mechanism, showing that TGFß-2 increases SPARC and a dual mechanism to increase IOP, mostly by altering the extracellular matrix. One of the most significant discoveries was that mice that can’t make SPARC don’t get glaucoma.
“We have elucidated a means by which IOP is regulated and likely discovered a new pathway by which disease modifying therapy can be established,” he said.
Editors’ note: Dr. Lewis, Dr. Samuelson, Dr. Rhee, and Dr. Herndon have financial interests with various ophthalmic companies. Dr. Brown has financial interests with Sight Sciences.
‘Reay of Hope’ offers dramatic complicated case videos
The 11th Annual Complications and “Reay of Hope” Video Case Presentations closed out ASCRS Glaucoma Day with Manjool Shah, MD, winning the award.
Dr. Shah presented the case of a 77-year-old patient with advanced glaucoma and an IOP of 17 mm Hg on three medications. He had an exposed tube that needed revision and he was monocular.
“Of course,” Dr. Shah said, introducing his video called “Oh Snap!”
After a lengthy discussion about the risks, Dr. Shah said the patient agreed to undergo the revision, which Dr. Shah alluded was not the complication. After getting to the tube, there was a little aqueous egress, Dr. Shah said, so his fellow went in to reform the chamber with a little viscoelastic and … pop.
“You could swear you could hear it in the OR,” he said, noting it was the fellow’s first time in the OR with him.
Descemet’s membrane was completely stripped off into the anterior chamber. Dr. Shah said they went into the newly viscoelastic-formed space and did a dry aspiration technique. After assessing the space, he pointed out how you could see Descemet’s coming up to the cannula. Multiple passes were taken in and out to clean up as much viscoelastic as possible. The viscoelastic was exchanged for air to keep the chamber formed, the tube procedure was finished, and the patient was supine for an hour postop in recovery.
Postop day 1 the patient was hand motion only with an IOP of 4 mm Hg and Descemet’s was still detached. What’s next? Dr. Shah said they talked about creating venting incisions through the stromal bed and rebubbling, rebubbling alone, or even a DSEK. Observation was selected. By postop day 4, the Descemet’s was still detached. Postop month 2, the cornea was more compact and Descemet’s was attached, but the patient’s vision was still poor. Poor vision continued at postop month 6. At 1 year, the patient was 20/150 and IOP stabilized around 10 mm Hg.
Editors’ note: Dr. Shah has no relevant financial interests.
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