Reporting from the 2021 AAO Annual Meeting
November 12–15, 2021 • New Orleans, Louisiana
- Controversies in cataract and refractive surgery
- Hot topics in ophthalmology
- Ophthalmic Premier League
- Management of retinal vasculitis
Controversies in cataract and refractive surgery
A Sunday afternoon session covered several “controversies” in cataract and refractive surgery. These included pediatric refractive surgery, presbyopia correction in non-cataract patients, and epi-on crosslinking. The session concluded with the Barraquer Lecture, delivered by Steven Wilson, MD, on the topic of corneal response to injury. Dr. Wilson detailed the work performed by himself and others over the years that has led to a better understanding of how the cornea responds and heals from an injury.
Deepinder Dhaliwal, MD, discussed refractive surgery in pediatric patients, explaining that candidates include children with refractive amblyopia who are intolerant or have poor compliance to conventional therapies or have spectacle-induced aniseikonia. Surgical techniques she spoke about included LASIK, SMILE, and phakic IOLs.
A pediatric LASIK study performed in 2000 included five patients with a mean myopia of –8.83 D, anisometropia, and failed attempts with spectacles and contacts. Four patients gained vision and one remained the same; all were within 3 D of their fellow eye and there were no significant complications. She noted the importance of using a laryngeal mask for general anesthesia to avoid laser malfunction. Two patients were followed out to 16 years, and both had stable vision, balanced refraction, improved stereopsis, and no ectasia.
While there is limited data in the pediatric population for SMILE, Dr. Dhaliwal discussed one study that looked at 124 eyes with 4 years of follow-up. The study saw a nice refractive result, she said, with less regression than PRK and LASIK and a high safety profile.
As for phakic IOLs, Dr. Dhaliwal said there are a lot of benefits but also the potential risks of intraocular surgery. She said there is a need for more prospective studies to evaluate ICL in this population.
Overall, Dr. Dhaliwal said she thinks pediatric refractive surgery is a viable option for the right patient, but careful discussion of the risk/benefits with the family is paramount.
Ashvin Agarwal, MD, presented on presbyopia-correcting IOLs and his use of a pinhole pupilloplasty technique. He discussed a few of the available presbyopia-correcting IOLs, but said he specifically uses EDOF and trifocal options.
For patient selection, he said those who are computer professionals and who drive a lot at night are better candidates for EDOF technology. Trifocals, he said, are ideal for people who want to be glasses free for most of their work throughout the day (though they’re not ideal for night driving).
Dr. Agarwal said with pinhole pupilloplasty, he estimates the optimal size of the pinhole that will deliver the best vision for each patient before surgery. This technique offers patients the best possible vision for distance, intermediate, and near with a field of vision that is not restricted. He also noted that the size of the pinhole can be modified postop with an Nd:YAG procedure, if needed. Another benefit of pinhole pupilloplasty, according to Dr. Agarwal, is that it costs less than presbyopic glasses and it likely costs less than a small-aperture IOL.
Editors’ note: Drs. Dhaliwal and Agarwal do not have financial interests related to their comments.
Hot topics in ophthalmology
A session on Sunday focused on the latest cutting-edge topics from different subspecialties. The presentations covered corneal neurotization, teprotumumab for thyroid eye disease (TED), the PRESERFLO MicroShunt (Santen), home-based glaucoma monitoring, artificial intelligence in the retina, enhanced monofocal IOLs, and epithelium-on crosslinking.
Roy Rubinfeld, MD, presented new Phase 2 results from the CXL-005 trial for a new method of epithelium-on crosslinking. He first gave an overview on the current state of prevalence of keratoconus, citing research published earlier this year that found it is much higher than previously thought, with 1.2% prevalence in a cohort of 20-year-olds. The adoption of crosslinking is nowhere near where it needs to be based on this prevalence, he said.
Why? In addition to needing to screen for disease to catch cases earlier, Dr. Rubinfeld noted limitations with the currently approved epi-off procedure, such as that it is limited to progressive keratoconus and its rehabilitation period. An epi-on procedure would have an improved risk/benefit, a shorter recovery period with reduced discomfort, and the potential for bilateral treatment, all of which could increase adoption.
Epi-on techniques have been researched for decades, with efficacy being an open question, Dr. Rubinfeld said. He went on to describe RiboStat, a fixed combination of riboflavin 0.5% and sodium iodide 0.015%, as part of the EpiSmart procedure. RiboStat, he said, preserves the riboflavin in the stroma and limits oxygen consumption, enhances penetration through intact epithelium, and prevents the breakdown of stromal riboflavin. There is also no need for additional riboflavin during the UV portion of the procedure and no need for oxygen supplementation. Dr. Rubinfeld said a novel, UVA light delivery device that can treat both eyes simultaneously was used in the study.
The prospective, randomized, controlled, open-label trial included patients 8 years and older upon diagnosis of ectatic disease. Average CDVA improved nearly a line in all keratoconus subjects in all groups, and UCVA gains were consistent with corrected visual acuity. There was consistent and significant flattening seen in Kmax, Dr. Rubinfeld said. Eighty-one percent of patients had stable or improved vision.
Dr. Rubinfeld compared data from this study to epi-off crosslinking data, showing how efficacy is essentially superimposable between the two. However, adverse events were more notable in the FDA epi-off data, compared to the EpiSmart, epi-on data. The epi-on procedure’s return to work was 1–2 days compared to 1–2 weeks with epi-off, and vision recovery was 1–2 days with epi-on compared to 3–10 weeks with epi-off. Epi-on also had the advantage of bilateral treatment, reduced pain, and fewer drops, among other things.
Dr. Rubinfeld concluded that this trial showed a greatly improved risk/benefit profile, with adverse events that are similar to prescription eye drops. This, combined with rapid recovery, Dr. Rubinfeld continued, would allow for bilateral, simultaneous treatments and treatment before progression with simple tomography.
Ilya Leyngold, MD, discussed the new procedure of corneal neurotization, which he described as the reinnervation of the cornea and adjacent ocular surface with an expandable adjacent sensory nerve, thereby reestablishing corneal integrity and sensibility.
There are many causes of corneal neurotrophic keratitis (NK) and several available treatments, but none of these treatments address corneal innervation, Dr. Leyngold said. Corneal neurotization was first described in the peer-reviewed literature in 2009, and since then, the procedure has been refined, with multiple techniques for direct and indirect transfer of donor nerves described.
He showed a video of a direct corneal neurotization procedure with an ipsilateral supero-orbital nerve. Dr. Leyngold shared outcomes data from corneal neurotization procedures. This included 85% of patients with persistent epithelial defects achieving closure. Ninety-two percent had ocular surface improvements, and there was a mean gain of 3.8 mm in corneal sensitivity. All 17 of the patients included in the paper said they would have the surgery again if they had the choice.
The surgical candidacy of a patient needs to be considered, Dr. Leyngold said, emphasizing that the patient needs to be consulted that it can take months to years to see improvement. While not necessarily a visual improvement procedure, it can lead to visual improvement, he said.
Future questions include the effect of nerve growth factor use with corneal neurotization, indirect vs. indirect corneal neurotization, allograft vs. autografts, and positioning of the fascicles.
Anne Barmettler, MD, gave an overview of teprotumumab (TEPEZZA, Horizon Therapeutics) for TED a year after its FDA approval. Teprotumumab improves proptosis, diplopia, and inflammation, after IV dosing every 3 weeks for 6 months. Clinical trial data with the drug showed 83% of patients had a 2 mm or more improvement in proptosis, but at 1.5 years, only 53% maintained that improvement. Sixty-eight percent of patients had improved with diplopia, maintained in 67% at 1.5 years.
In a real-world setting, Dr. Barmettler said patients are showing improvement, especially in proptosis. She noted, however, that improvement is not 100%; some patients will still need surgery after infusions, and some patients are reoccurring. In terms of side effects, Dr. Barmettler said 10% of patients had an increase in blood glucose and 10% also had hearing loss or hearing changes. IBD exacerbations and amenorrhea were also side effects in some patients.
From a logistics standpoint, Dr. Barmettler said it is an expensive procedure (up to $300,000 per patient) with an extensive prior authorization process, and some insurances require criteria to be met before coverage. There are also logistics involved with infusions.
Editors’ note: Drs. Leyngold and Rubinfeld have financial interests with several ophthalmic companies. Dr. Barmettler does not have financial interests related to her comments.
Ophthalmic Premier League
The Ophthalmic Premier League symposium featured several teams “competing” in managing complicated cataract cases, sharing a variety of surgical videos.
Nicole Fram, MD, showed several videos to help demonstrate when to use a lasso fixation technique vs. when to do an IOL exchange.
Candidates for a lasso, she said, are those with a single-piece acrylic IOL that is fully in the bag, patients who were happy with their refractive results, and those with small, symmetrical Soemmerring’s ring.
Meanwhile, Dr. Fram suggested doing an IOL exchange in patients with loose zonules or a dead bag, if the patients were never happy with the IOL optics, and if there is large or asymmetric Soemmerring’s ring.
Kevin Miller, MD, shared a case where he inserted an iris prosthesis for a congenital aniridic patient. He started by putting in trypan blue and dispersive OVD. He used a clear corneal tunnel incision and noted that he could use a small capsulorhexis.
He also noted the importance of making sure the capsule is completely clean in these artificial iris cases. Dr. Miller was careful to ensure that he got all cortex and lens epithelial cells out, which required careful polishing of the anterior capsule.
He noted that he had a difficult time getting the subincisional area, so he made another incision to polish this because he didn’t want to leave anything behind. It’s important to go behind the IOL and perhaps spin the lens, to make sure every last lens epithelial cell is out.
When it came time to insert the iris prosthesis, Dr. Miller inserted it untrephinated. He stressed the importance of tapping the iris prosthesis all the way around to ensure that it’s firmly in the ciliary sulcus.
Dr. Miller used an unsutured technique, which he said is “controversial” in the artificial iris community. The patient ended up with great cosmetic and functional results.
Eric Donnenfeld, MD, mentioned the importance of improving the quality of LRIs. He specifically discussed intrastromal arcuate incisions. Though these are less effective than full thickness incisions, he said that some of the advantages are that Bowman’s membrane remains intact, there is less pain, no need for antibiotics, and more.
Automation of intrastromal LRIs improves surgical outcomes by incorporating posterior cylinder, vector analysis of primary incision, and cyclotorsion, Dr. Donnenfeld said, adding that this all eliminates input error and helps reduce planning time. This is an example of “working smarter,” he said.
Editors’ note: Drs. Miller, Donnenfeld, and Fram have financial interests with a variety of ophthalmic companies.
Management of retinal vasculitis
Narsing Rao, MD, gave the C. Stephen and Frances Foster Lecture on Uveitis and Immunology on the topic of “A Practical Framework for Management of Retinal Vasculitis.”
The generally accepted definition of vasculitis, he said, is inflammation of the blood vessel wall supported by histopathology. But he noted that clinically, such histologic support is not feasible in the diagnosis of retinal vasculitis. Ophthalmologists typically cannot clinically obtain tissue for diagnosis, he said.
The primary clinical diagnosis of retinal vasculitis includes the presence of cells in the vitreous, fluffy white sheathing, and fluorescein leakage from vessels.
Although retinal vasculitis is a clinical diagnosis, Dr. Rao said ophthalmoscopy provides visualization of retinal vascular changes useful in diagnosis of retinal vasculitis associated with systemic and chorioretinal diseases.
Dr. Rao noted two immunological concepts of vasculitis and perivasculitis. 1. In retinal vasculitis, inflammation starts from vascular lumen endothelium and extends outward toward adventitia. 2. In retinal perivasculitis, inflammation may start in adventitia due to the presence of immunoreactive cells in glia limitans and spread inward toward endothelium.
Retinal vasculitis is not an etiologic diagnosis, Dr. Rao said, adding that it can be part of systemic vasculitis with other single or multi-organ involvement, or it can be limited to the retina.
To exclude mainly primary systemic vasculitides, ophthalmologists usually seek a rheumatology consult. But prior to such a referral, he said it’s important for ophthalmologists to be familiar with nomenclature commonly employed by rheumatologists so that a focused workup to detect primary systemic vasculitis can be undertaken.
Retinal vessels are primary small vessels, Dr. Rao stressed.
He proposed a framework for management of retinal vasculitis divided into three groups: associated with systemic diseases, organ limited retinal vasculitis, and probable etiology.
Within the group associated with systemic diseases, Dr. Rao also included small vessel primary vasculitides, variable vessel vasculitides, and infectious and non-infectious systemic diseases. In the organ limited retinal vasculitis group, he included groups associated with infectious retinitis or choroiditis, non-infectious retinitis and or choroiditis, and idiopathic. His presentation also highlighted some potential treatment options for the various groups.
In summary, Dr. Rao said that retinal vasculitis is a combination of clinical features, imaging, and lab investigations that can establish clinical diagnosis of retinal vasculitis. Retinal vasculitis can be of systemic disease, or it can be localized without systemic disease, he said.
A rheumatologic approach, based on vessel size, is helpful in primary vasculitides, he said, and treatment can vary.
Editors’ note: Dr. Rao has no financial interests related to his comments.
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