EyeWorld/ASCRS reporting live from AAO 2019 in San Francisco, Sunday, October 13, 2019


EyeWorld/ASCRS reporting live from AAO 2019 in San Francisco, Sunday, October 13, 2019
AAO 2019 officially kicked off on Sunday with its opening session. A variety of other symposia and sessions throughout the day covered cornea, cataract, and refractive topics, and more.
Controversies in cornea
A Sunday morning symposium highlighted a number of subjects in cornea and saw experts debating on either side of these “controversial” topics.
On the topic of adenoviral conjunctivitis, Jessica Ciralsky, MD, New York, argued that there will never be a therapy/cure and the best option is to prevent the spread.
Adenoviral conjunctivitis is the “bane of every ophthalmologist’s practice,” she said. It’s characterized by watery, red eyes, discharge, eyelid swelling, and it spreads quickly to the second eye. It was first described over 100 years ago, she said, and there still is not a good treatment option. It affects 6 million people in the U.S. annually, Dr. Ciralsky said, and can be persistent. It’s also highly contagious.
To diagnose, Dr. Ciralsky said you can use cell culture or an in-office diagnostic. Viral cultures are not routinely done, she said, adding that using a slit lamp for diagnosis is also recommended.
A lot of these patients are going to urgent care, primary care, or not coming in at all, she said. Both misdiagnosis and mistreatment are issues with adenoviral conjunctivitis. Even when patients present to an eye doctor, Dr. Ciralsky said clinical inaccuracy can still occur, and the inability to initiate proper prevention methods leads to disease spread. She added that unnecessary use of antibiotics is also a problem.
Dr. Ciralsky suggested focusing on prevention. For the patient, she recommended strict handwashing, home disinfectants, and avoiding contact with others. For the ophthalmologist, she recommended use of appropriate cleaners, considering a special room for infectious patients, and using disposable instruments.
Meanwhile, on the other side of the issue, James Chodosh, MD, Boston, argued that there will be a treatment in the future.
He first noted promise in newly identified antiviral agents, particularly pointing to repurposed drugs: salicylanilide anthelmintic drugs, mifepristone, and cardiotonic steroids. He also said that brincidofovir has shown promising results, particularly in bone marrow transplant recipients with systemic adenovirus infections.
Dr. Chodosh said that given the avalanche of new molecular diagnostics, he believes that there will eventually be a rapid, nucleotide-based, in-office test that works well. He added that the potential impact of a drug with efficacy against adenoviral conjunctivitis is high and will continue to attract interest from pharma, and he stressed that already FDA-approved drugs that have been repurposed for ocular use continue to be explored.

Editors’ note: Dr. Ciralsky has no relevant financial interests. Dr. Chodosh has financial interests with Shire.

Imaging for the anterior segment specialist
The Cornea Society-sponsored symposium highlighted a variety of imaging topics. During the session, Carol Shields, MD, Philadelphia, discussed “Imaging of Suspicious Anterior Segment Lesions: UBM for Iris and Ciliary Body Lesions.” She particularly noted differences between using ultrasound biomicroscopy (UBM) and anterior segment-OCT (AS-OCT).
She noted that UBM is preferred if the tumor is deep and dark, particularly in the iris stroma, iris pigment epithelium, or ciliary body. Meanwhile, AS-OCT is preferred for superficial and light lesions of cornea, conjunctiva, and iris stroma.
Dr. Shields also described her study “Assessment of Anterior Segment Tumors with Ultrasound Biomicroscopy versus Anterior Segment Optical Coherence Tomography in 200 Cases.” The study found that, for anterior segment tumors, UBM offered better visualization of all margins and overall better images for entire tumor configuration, Dr. Shields said. But these techniques can be complementary with tumor shape by UBM and corneal/angle/aqueous details by AS-OCT.

Editors’ note: Dr. Shields has no relevant financial interests.

Opening session
During the opening session, Emily Chew, MD, Bethesda, Maryland, gave the Jackson Memorial Lecture on the topic of “Age-related Macular Degeneration: Nutrition, Genes, and Deep Learning.” In early AMD, you may see medium-size drusen, but late stages of AMD are potentially vision threatening, she said.
Dr. Chew went on to discuss the Age-Related Eye Disease Study (AREDS) and AREDS2. Epidemiologic studies suggested nutrition may be important, and AREDS found that a combination of vitamins and zinc could be helpful. Meanwhile, AREDS2 sought to look at more factors, including Omega-3 and lutein/zeaxanthin.
Dr. Chew also highlighted how the Mediterranean diet relates to AMD, noting that this diet is associated with decreased progression of late AMD in those with intermediate AMD, decrease in progression of large drusen (from early AMD), and an effect that appears to be important in both early AMD and those with intermediate AMD. It may never be too late to start a Mediterranean diet, she said.
During her lecture, Dr. Chew also discussed genetics and artificial intelligence and deep learning. She said that the goals for using deep learning were to detect features of AMD, particularly large drusen, reticular pseudo-drusen, pigmentary changes, and late AMD (neovascular or geographic atrophy); to classify the severity of AMD on a personal level; and to predict the risk of progression. She described a study using DeepSeeNet, a “deep learning model for automated classification of patient-based age-related macular degeneration severity from color fundus photographs.”
In the study, the performance of DeepSeeNet was compared to 88 retinal specialists. It found that, in almost all instances, deep learning was superior to the human gradings for detection of drusen and pigmentary changes, however, Dr. Chew noted that, for late AMD, deep learning was not superior to the human gradings. In summary of the study, she said that “by simulating the human grading process, DeepSeeNet demonstrated high accuracy in the automated assignment of individual patients to AMD risk categories based on the AREDS simplified severity scale.” She added that deep learning will not replace the ophthalmologist, but rather it will enhance diagnostic skills and improve clinical management in the future.

Editors’ note: Dr. Chew has no relevant financial interests.

Spotlight on artificial intelligence and new technology for the ophthalmologist
Rob Melendez, MD, Albuquerque, New Mexico, provided a brief history of artificial intelligence and offered definitions for AI and machine learning in this Sunday morning session. Dr. Melendez defined artificial intelligence (AI) as the science of training machines to do human tasks. Machine learning, he said, is the method behind how machines learn from data. Following were presentations on AI in ophthalmology, big data, 3D retina, 3D cataract, 3D ophthalmic printing, and the top 10 apps in the field.
Naama Hammel, MD, San Francisco, a clinical research scientist and a glaucoma specialist by training, works on a team at Google that applies machine learning to medical data. Overall, Dr. Hammel said, it’s now easier to program a computer to learn than to hard code it to be smart.
Machine learning is useful when there is a lot of data to look through but limited expertise. For example, there are more than 400 million people in the world with diabetes, Dr. Hammel said. Even if all of these patients were imaged, there aren’t enough trained professionals to look through these images to grade for diabetic retinopathy. Dr. Hammel described how AI programs have been and are being developed to read fundus images to screen for diabetic retinopathy. Other applications for machine learning in ophthalmology that are in the works are detection of diabetic macular edema from fundus photography that is on par with OCT accuracy and prediction of AMD progression, Dr. Hammel said.
Currently, the biggest challenge facing machine learning is consistent labeling, Dr. Hammel continued. Labels come from clear disease definitions and clear severity scales. These, she said, can only come with help from clinicians and doctors.
John Ladas, MD, PhD, Baltimore, discussed artificial intelligence in ophthalmology, specifically how he thinks it could help ophthalmologists navigate a set of variables or direct intervention toward a desired outcome. He and a team of researchers are working on developing a “self-calibrating” biometer that could enhance cataract surgery outcomes. Variables from the optical biometer would be put into a deep-learning program to calculate IOL power and select a lens. Postoperative outcomes would provide more data and then drive algorithm optimization, which would then help better calibrate the optical biometer. Dr. Ladas said goal of this project is to generate automated, objective data from millions of eyes, integrate lens calculations, tailor to individual surgeons, and create a system that evolves in perpetuity.

Editors’ note: Dr. Hammel has financial interests with Google. Dr. Ladas does not have financial interests related to his comments.

'Cataract Surgery: The Cutting Edge'
Some of the latest innovations in cataract surgery were presented at this symposium.
Richard Lindstrom, MD, Minneapolis, provided a brief update on pharmaceuticals that received FDA approval in 2019. There were 129 drugs in all fields of medicine approved in 2019—seven related to ophthalmology. In previous years, Dr. Lindstrom said, new approvals were about four.
The approvals included YUTIQ (EyePoint Pharmaceuticals), DEXTENZA (Ocular Therapeutix), LOTEMAX SM (Bausch + Lomb), Rocklatan (Aerie Pharmaceuticals), Avaclyr (Fera Pharmaceuticals), tetracaine hydrochloride ophthalmic solution (Bausch + Lomb), and Beovu (Novartis)
Following, Edward Holland, MD, Cincinnati, gave an update on corneal surgery. While DMEK is becoming more and more popular, Dr. Holland said he thinks there are still indications for DSAEK. Studies, he continued, show better visual outcomes with thinner DSAEK tissue. Dr. Holland went on to describe a prospective trial published last year that compared DMEK and nano-thin DSAEK. At 1 month, the DMEK eyes saw better, but at 3, 6, and 12 months, visual acuities in the nano-thin DSAEK group caught up, he said. Precut, preloaded nano-thin DSAEK tissue will be available soon, Dr. Holland said.
Dr. Holland also touched on the applications for topical rho kinase inhibitors for the treatment of early corneal edema and as an adjunct for Descemet’s stripping only. He also mentioned the artificial endothelium EndoArt (EyeYon Medical), cultured endothelial cell injection therapy, 3D-printed corneas, and CorNeat KPro (CorNeat Vision).
Other presentations updated on refractive surgery, glaucoma, diagnostics, visualization, and more. Robert Osher, MD, Cincinnati, chair of the symposium, closed out the session with information on instruments, devices, and miscellaneous cutting-edge items. These included artificial intelligence; capsulotomy devices (like CAPSULaser [Excel-Lens]); robotic photoemulsification with a device by Keranova; visualization technology by BeyeOnics; a new drape with a cooler feeling, more transparency to reduce claustrophobia, and reduced adhesive (Beaver-Visitec International); OR air filtration; and more.

Editors’ note: Dr. Lindstrom has financial interests with Novartis and Ocular Therapeutix. Dr. Holland and Dr. Osher have financial interests with a number of ophthalmic companies.

Ophthalmic Premier League
The Ophthalmic Premier League, led by Amar Agarwal, MD, Chennai, India, and Dr. Lindstrom, consisted of four teams each with four presenters who presented for 4 minutes each. During the session, Elizabeth Yeu, MD, Norfolk, Virginia, explained how to explant and exchange IOLs. It varies from eye to eye, but being prepared with all the instruments, IOL options, and sutures is key, she said. Instruments you need include a flat paddle (Koch spatula), a hooked instrument, IOL intraocular scissors and forceps, viscoelastic devices, vitrectomy, and glue or sutures.
Nicole Fram, MD, Los Angeles, described management of positive and negative dysphotopsias. Positive dysphotopsias, Dr. Fram said, consist of light, streaks/arcs, flashes, and starburst, while negative dysphotopsias are temporal dark shadows. Positive dysphotopsias can be treated with pharmacological agents (brimonidine 0.15% or pilocarpine 0.5%) or removal and replacement with a different IOL material. Negative dysphotopsias, if they don’t resolve over time, can be managed with reverse (anterior) optic capture or a sulcus-placed IOL. A piggyback IOL or nasal capsulectomy could be considered, she said.
Other presentations included pinhole pupilloplasty for post-RK eyes, use of an IOL scaffold, a four-flanged IOL-fixation technique, glued IOLs, and more.

Editors’ note: Dr Yeu and Dr. Fram do not have financial interests related to their comments.

EyeWorld Onsite is a digital publication of the American Society of Cataract and Refractive Surgery and the American Society of Ophthalmic Administrators.

Medical editors: Eric Donnenfeld, MD, chief medical editor; Rosa Braga-Mele, MD, cataract editor; Clara Chan, MD, cornea editor; Nathan Radcliffe, MD, glaucoma editor; Vance Thompson, MD, refractive editor

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