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| | Highlights from AAO 2015 and Subspecialty Day
Why Big Data Is a Big Deal
During Sunday’s Opening Session, the 2015 Jackson Memorial Lecturer—Anne L. Coleman, MD, PhD—provided some historical perspective on cataract surgery, before describing why Big Data would play a critical role in its future.
Underlining how far procedures have evolved, Dr. Coleman cited an early 20th century study that compared cataract couching with cataract extraction. A successful outcome was defined as vision of at least 20/200—“not great by today’s standards.”
Since then, “we have made huge advances in the techniques of cataract surgery and in the types of antibiotics we use, but we still have those people who get endophthalmitis.” The rarity of this complication poses a challenge for researchers. “Enter Big Data,” said Dr. Coleman.
After referencing several studies of endophthalmitis drawn from large data sets—including U.S. Medicare claims, electronic health records, and the Swedish National Cataract Surgery Registry—Dr. Coleman reported some results from her own research.
She analyzed a 5% sample of Medicare claims data for 4 successive years (2010-2013; 216,703 individuals) and 2 years of data from the IRIS Registry (2013-2014; 511,182 individuals), which includes clinical information, such as visual acuity (VA), unavailable in the Medicare data set.
The endophthalmitis rates were 0.14% and 0.08% based on the Medicare and IRIS Registry data, respectively. Why the difference? First, the IRIS Registry patients are younger. Second, some patients might have undergone cataract surgery by an IRIS Registry participant and later followed up with a nonparticipant. Third, the Medicare claims data set doesn’t indicate laterality, which means the endophthalmitis isn’t necessarily in the same eye that had surgery.
“Big Data is a tool, and it’s really up to us how to use it,” said Dr. Coleman. “The discoveries made with the IRIS Registry will help improve care and decrease the rate of endophthalmitis in the future.”—Chris McDonagh
Learn more about the IRIS Registry while you’re at AAO 2015.
For financial disclosures, see this article on the EyeNet section of aao.org.
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Genetic Testing in Glaucoma
Just because you can order genetic testing for a patient doesn’t mean you should. “Genetic testing is rarely indicated in glaucoma,” said Wallace L.M. Alward, MD, at Glaucoma Subspecialty Day on Saturday.
However, he emphasized that there are circumstances in which testing—and genetic counseling—is essential. If there’s a family history of glaucoma, “families need to know,” Dr. Alward said. “Even with primary open-angle glaucoma, there’s a 22% increase in risk for first-degree relatives.”
Dr. Alward offered 2 compelling reasons for testing from his own practice:
- A male aniridia suspect who was adopted and who now has 3 children of his own. Does the father have primary congenital glaucoma or Axenfeld-Rieger syndrome? “If it’s Axenfeld-Rieger, the children have a 50-50 chance of developing the disease [glaucoma],” Dr. Alward said.
- Members from a large family study of juvenile-onset open-angle glaucoma. “One patient now has 2 children of her own. These children deserve close follow-up.”
The first step is to obtain baseline disc photos of the patient, Dr. Alward said. Beyond that, genetic tests can be ordered singly or in combination. And while they also can be ordered as part of a larger panel, “There’s no reason to order a massive panel,” Dr. Alward advised. He recommended www.genetests.org as a source of additional information.—Jean Shaw
For financial disclosures, see this article on the EyeNet section of aao.org.
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Managing Acute Stevens-Johnson Syndrome
At Cornea Subspecialty Day on Saturday, Anthony Johnson, MD, emphasized the importance of early intervention in managing the ocular surface complications of Stevens-Johnson syndrome (SJS).
Because SJS patients are seriously ill and are generally managed in the hospital by burn specialists, their eye problems may be overlooked until severe ocular surface damage has occurred, such as cicatricial changes and limbal stem cell loss. Dr. Johnson said that he has not observed much correlation between the severity of the skin and eye manifestations, and he stressed the importance of assessing SJS patients as soon as possible for signs of ocular disease. Burn specialists should be educated about the need for timely ophthalmic consultation.
Any fluorescein staining of the conjunctiva, cornea, or fornix, or changes in the eyelid margins indicate the need for ophthalmic treatment. Dr. Johnson compared treatment to “cordoning off the fire” and emphasized that the goal is to deal with the inflammation primarily, rather than trying to catch up after the formation of symblephera and onset of cicatricial changes.
According to Dr. Johnson, the mainstay of treatment is to cover the entire ocular surface, including the outside and inside of the eyelids, with amniotic membrane. The membrane provides both anti-inflammatory effects and mechanical protection.—Peggy Denny
For Dr. Johnson’s treatment approach using amniotic membrane and for his pearls, see this article on the EyeNet section of aao.org.
Dr. Johnson has no financial disclosures
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Wang-Koch Formula and IOL Power in Long Eyes
How can cataract surgeons reduce the likelihood of “hyperopic surprise” in eyes with long axial lengths? This was one of many topics discussed during Sunday morning’s Cataract Original Papers session.
Nicole R. Fram, MD, and her coauthors compared the ability of intraoperative aberrometry and 3 relatively new formulas—Wang-Koch, Olsen, and Barrett Universal II—to accurately predict IOL power in long eyes. They found that while all of the options performed well, the Wang-Koch formula proved to be statistically superior.
For this retrospective study, the researchers reviewed 52 eyes (39 patients) with axial lengths greater than 25 mm. All cataract extractions were performed through 2.2-mm incisions, and all of the surgeries were uncomplicated. Mean absolute error was 0.24 for intraoperative aberrometry, 0.12 for the Wang-Koch, 0.40 for the Olsen, and 0.35 for the Barrett Universal II.
In discussing the paper, Dr. Fram said that her takeaway from the research wasn’t necessarily that cataract surgeons should automatically rely on the Wang-Koch formula without considering other options. Instead, she said, it’s more a matter of consolidating information and having the highest possible level of confidence. “Aren’t we fortunate to have multiple formulas to compare and use to make a decision at the time of surgery?” she concluded.
The report was selected as “best paper” during the Sunday session of Cataract Original Papers. Dr. Fram’s coauthors were Samuel Masket, MD, Li Wang, MD, PhD, and Douglas D. Koch, MD.—Jean Shaw
For financial disclosures, see this article on the EyeNet section of aao.org.
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Peds Experts: What I Never Knew
Saturday’s Pediatric Ophthalmology Subspecialty Day concluded with true confessions from the experts. Here is some top advice:
- Edward G. Buckley, MD: Use a tonsil snare for enucleation for better hemostasis, long optic nerve stump, and minimal “crush” artifact at the cut nerve ending.
- Sean P. Donahue, MD, PhD: Cerebrotendinous xanthomatosis is a rare autosomal recessive condition, usually presenting with chronic diarrhea from infancy, bilateral cataract in the first 2 decades, and xanthomatosis on the tendons. Gene testing can confirm the diagnosis.
- Constance E. West, MD: Much of the ophthalmic encounter occurs in dim lighting, but remember to turn on the lights and look at your patients’ ears, face, teeth, and skin; otherwise, you might miss port-wine stains (Sturge-Weber) and tilted glasses (against-the-rule astigmatism). Also, question cardiac development and neurological history.
- David B. Granet, MD: Superior oblique sharpening for Brown syndrome over traditional superior oblique stripping for a higher success of correction.
- Stacy L. Pineles, MD: IgG4 disease usually presents with painless eyelid swelling and an enlarged lateral rectus muscle, [which] can help differentiate it from thyroid eye disease. The presence of coexistent lacrimal gland, infraorbital nerve, and paranasal sinus disease can help to confirm the diagnosis.
- Alex Christoff, CO: “When in doubt, the least expensive test you can order is a return visit to the office.”
- Katherine A. Lee, MD, PhD: Have patience for your patients. The Open Notes Initiative allows for more transparency and better communication between doctor and patient.—Reporting by Keng Jin Lee
For financial disclosures, see this article on the EyeNet section of aao.org.
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FluidVision Accommodating IOL: 2 Years of Data
With 24 months of data now available, the FluidVision IOL appears to be closer to fulfilling its promise as an IOL that is genuinely capable of mimicking natural accommodation.
Louis D. “Skip” Nichamin, MD, presented study results during the Cataract Original Papers session on Sunday. The initial pilot study of 26 eyes was conducted in Pretoria, South Africa. With regard to follow-up, 24-month data are available on 16 of the eyes, while 18-month data are available on 19 eyes.
Dr. Nichamin reported that patients were achieving 20/20 acuity across the range of vision (near, intermediate, and distance) with the FluidVision IOL. Moreover, the IOL provides a stable 3 to 4 D of accommodation, he said. However, uncorrected distance vision data were not available.
Dr. Nichamin described the IOL as a “continuously variable monofocal” device. It uses the power of the ciliary body to pump fluid from the haptics to the optic. A larger study with up to 3 years of follow-up is under way.—Jean Shaw
For financial disclosures, see this article on the EyeNet section of aao.org.
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What to Expect After Childhood Glaucoma
When it comes to teens and adults who had childhood glaucoma, “the diagnosis just follows them, whether it’s the consequence of the disease or of our treatment,” said Alana L. Grajewski, MD, at Glaucoma Subspecialty Day on Saturday.
Overall, it’s best to think of childhood glaucoma as a panocular disease, as it affects every part of the eye, including the cornea, sclera, iris, and zonules, Dr. Grajewski said. “Increased intraocular pressure [IOP] in a developing eye is different [from in the adult eye]; it has a lot of moving parts. It affects corneal physiology and biomechanics,” she said. “Scleral elasticity happens fast and doesn’t reverse, which causes problems later on. Visual field defects persist, even if the patient’s pressure is normal later in life.”
How likely is it for glaucoma to recur in a patient who was treated as a child? That will depend on the initial severity of the patient’s disease and on the number of surgeries he or she had, Dr. Grajewski said. In general, patients tend to return for treatment at 2 particular times in their life, she noted: The first is at puberty, when hormones can wreak havoc with IOP. The second is when they begin having children themselves and may want to discuss genetic testing.—Jean Shaw
Dr. Grajewski has no financial disclosures.
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The Quotable Ophthalmologist
“When I am about to leave the room, I always ask my patients if they have any questions. And then I wait for almost an uncomfortable period of time for them to respond,” said Constance E. West, MD, while sharing tips on history taking and the patient exam.
“We treasure direct patient contact—or else we would have been radiologists,” said David W. Parke II, MD, during Sunday’s Opening Session.
A range of responses from the Story Wall asking, “Why did you become an ophthalmologist?”
“I wanted everyone to see the beauty of the world.”
“Cataract surgery is like playing PlayStation—it’s fun!”
“There are 2 eyes … double the work!”
(The Story Wall is located in the Grand Foyer.)
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Guest Medical Editor:
Steven I. Rosenfeld, MD
Managing Editor:
Chris McDonagh
Editors:
Patty Ames, Peggy Denny, and Susanne Medeiros
Writers:
Keng Jin Lee and Jean Shaw
The articles in Academy Live come from events and presentations that took place during Subspecialty Day and the Annual Meeting of the Academy, and are not the product, opinion, or position of the Academy unless explicitly stated to be so. The Academy does not endorse products, companies, or organizations. The Academy disclaims all liability.
If you would like to update your email address or be removed from the mailing list, send a request to eyenet@aao.org. Questions? Comments? Email Chris McDonagh at cmcdonagh@aao.org.
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