June 2018

NEWS & OPINION

Insights
When the lines blur


by J.C. Noreika, MD, MBA


J.C. Noreika, MD, MBA

Insights gathered from presentations at the 2018 ASCRS•ASOA Annual Meeting converge to reveal a path to sustainable functional vision after cataract surgery in our most vulnerable patients

Some impressions of big-room themes at the 2018 ASCRS•ASOA Annual Meeting: microinvasive glaucoma surgery (MIGS) redraws territorial stakes between glaucoma specialist and anterior segment surgeon; cataract specialists chase “perfect” outcomes while conceding that perfection, a construct defined by the patient, is denied mere mortals; the sublimity of a femtosecond laser capsulorhexis may yield to a more economical nitinol handheld device; and can lipoic acid choline ester eye drops really heal the heartbreak of presbyopia?
But the keenest insights were gained in small rooms of less trumpeted presentations. Culled from seemingly unrelated podia, these ideas coalesced into new understanding of vexing puzzles. Carl Jung coined this metaphysical phenomenon “Synchronicity.”
On Sunday afternoon, a small gathering of the curious attended a scientific paper session succinctly titled “Maculopathy.” Its categorical label, Retina, seemed as befitting the ASCRS meeting as a ballerina at a Texas two-step bar. Synchronicity doesn’t dictate coincidence.
An earlier panel discussion left unsettled whether optical coherence tomography (OCT) should be part of preoperative cataract workups. Ophthalmologists don’t need another mandate on their preop checklists. Yet assessing macular health prior to surgery can avoid the disappointment of unfulfilled expectations postoperatively. OCT technology is widely available, its sensitivity and specificity well established and patient acceptance high. Negatives? Time, i.e., another station stop on the preop express, and money, viz., who pays its fixed, variable and sunk costs? How much treatable pathology will be revealed? No one knows.
Dr. Allen C. Ho’s paper presented in the “Maculopathy” session inspired my Jungian moment. Apportioning big data of the AAO IRIS Registry, Dr. Ho stratified patients with wet macular degeneration by treatment outcome. He confirmed two compelling correlates: the size of the membrane when first treated and the patient’s presenting vision.
“Decreasing the time between onset of disease and initiating anti-VEGF treatment is the key to improving outcomes and maintaining functional vision,” Dr. Ho told me. From the patient’s perspective, functional vision, not improvement in Snellen chart performance, is the meaningful endpoint. Dr. Ho cited research suggesting wet AMD is present in eyes 7.7 months prior to initial treatment. In the Registry, only 34% of eyes had 20/40 or better vision at the time of the initial injection. Mean vision at initial treatment was 20/83. In fellow eyes developing new vessel membranes, the vision before first treatment was 20/79. As data from the Beaver Dam Eye Study showed that AMD is a symmetric disease,1 this suggests a problem.
AMD is the leading cause of vision loss in the elderly in the United States. The National Eye Institute (NEI) of the National Institutes of Health (NIH) found whites, the ethnic group at greatest risk, exhibit a sevenfold increase in prevalence of AMD between ages 70 and 74 (2%) and 80 and older (14%). The NEI projects that 3.7 million—about the population of Los Angeles—will have macular degeneration by the year 2030. Using U.S. Census Bureau estimates, a quick and dirty analysis suggests that more than 20% of patients older than 75 will contend with AMD.
Its risk factors are well known; age, history of smoking, cardiovascular disease and family incidence are inculpated. Genetic predisposition is less clear but recent genome-wide association studies (GWAS) state that “two loci in particular, including genes of the complement cascade on chromosome 1 and the ARMS2/HTRA1 genes on chromosome 10, have been shown to convey significantly increased susceptibility to developing AMD.”2 The report concedes that 35% of AMD heritability remains unknown and may be unknowable. No quick fix is in the offing.
Ophthalmology is a geriatric specialty. By pinpointing populations at risk and pro-actively diagnosing patients with small lesions, eye surgeons can provide an enormous public benefit that needn’t be onerous. A Caucasian female, age 87, with a history of tobacco use and taking cardiac medications presents with a nuclear sclerotic cataract. Her brother died legally blind. She deserves our best effort to exclude vision-compromising complications preoperatively. Her workup mandates a posterior segment OCT. Perfect IOL power determination, a flawless capsulorhexis, and a toric implant exquisitely positioned to correct astigmatism will count for nothing if a neovascular lesion threatens the fovea.
What of the same patient at age 70 presenting with nuclear sclerosis and a high level of visual function? Fundus evaluation shows drusen and pigmentary changes scoring as intermediate risk for NVD development? Annual evaluations with serial OCTs may be too little, too late to discover a small lesion. Dr. Ho volunteered another option.
Notal Visions’ ForeseeHome is an FDA-approved home telemonitoring system that allows patients to test daily for subtle variations caused by AMD activity. The test takes 3 minutes. The NIH ended a large, multicenter study 6 months early as the device identified patients exhibiting small changes earlier than other methods. According to the AREDS2 Home Study Research Group, 94% of patients who converted to wet AMD while using the ForeseeHome system and an Amsler grid maintained >20/40 vision after treatment compared to 64% using other techniques. Early detection and treatment makes a difference. Dr. Ho stated that other devices such as DigiSight Technologies’ Paxos and Vital Art and Science’s mVT App are commercially available.
Prescribing telemonitoring devices for appropriate subjects and obtaining preop OCTs in high-risk patients, cataract surgeons can help mitigate senescence’s burden. Medicare agrees; reimbursement has been approved. Aging’s debility is inevitable but its slope can be bent by the judicious application of technology.
Synchronicity sometimes is found in smaller rooms along quieter, less traveled corridors of inquiry if one is willing to look. This year’s meeting proved no exception.

References

1. Gangnon RE, et al. Severity of macular degeneration in 1 eye and the incidence and progression of age-related macular degeneration in the fellow eye: the Beaver Dam Eye Study. JAMA Ophthalmol. 2015;133:125–32.
2. Black JR, et al. Age-related macular degeneration: genome-wide association studies to translation. Genetics in Medicine. Genet Med. 2016;18:283–9.

Editors’ note: Dr. Noreika has practiced ophthalmology since 1981. He has been a member of ASCRS for more than 35 years. Join the discussion on this article and others on the EyeWorld blog at blog.eyeworld.org.

Contact information

Noreika
: jcnmd@aol.com

When the lines blur When the lines blur
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