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Hawaii 2002 shows specialty’s progress
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WAIKOLOA, Hawaii — More than 800 eye care professionals gathered here for a timely update on clinical topics in ophthalmology. The take-away message, participants said, was that incremental improvements in ophthalmic technique and technology continue to advance the quality of patient care and the level of patient satisfaction.
Altogether, more than 1,000 people attended Hawaii 2002, The Royal Hawaiian Eye Meeting, sponsored by Ocular Surgery News in conjunction with the New England Eye Center. The meeting was held here at the Hilton Waikoloa Village resort.
The refractive surgery program at the meeting was particularly heavy with news of developments in customized ablation. The general session program also provided physicians with the latest research on cataract, glaucoma and cornea/external disease. New products, and new results with familiar products, were discussed in well-attended sessions and symposia.
AcrySof N series IOL
On the cataract front, Kerry Solomon, MD, told attendees about a new AcrySof lens, which absorbs light like the human lens. The AcrySof N SB30 series single-piece lens (Alcon) provides an ultraviolet spectrum similar to the human crystalline lens, Dr. Solomon said.
“What makes this lens different is the addition of 0.04% covalently bonded yellow dye. This lens was designed to approximate the natural human crystalline lens throughout the aging process,” he said.
He added that patients who have the lens implanted will not have their color perception affected by the yellow tint on the lens.
Dr. Solomon said there was no difference in visual acuity, color perception or contrast sensitivity in patients who received the traditional AcrySof SA30 lens, compared with patients who received the N series lens in a study of 300 patients. No adverse events were reported in the study, he added.
Alcon officials anticipate Food and Drug Administration approval of the lens by the end of year.
Phaco with less heat buildup
Barry Seibel, MD, spoke about the Avantix phacoemulsification system, which allows for phaco through a 1.2-mm incision, causing less heat buildup than traditional phaco technology.
Dr. Seibel said that the Avantix system (Bausch & Lomb) also requires less manipulation than standard ultrasound.
The Avantix system, previously known as the Catarex system, more effectively allows true endocapsular emulsification with subsequent maximum protection to the corneal endothelium, Dr. Seibel said.
Artisan lens shows good results
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In sessions regarding non-excimer refractive procedures, one surgeon reported that the Artisan Myopia Lens implant appears to be safe and effective within the correction range of –5 D to –20 D.
Elizabeth Davis, MD, presented 12-month postop results of a phase 3 U.S. study of 769 eyes of 447 patients.
“For the high ranges of correction, corneal refractive surgery is not ideal,” Dr. Davis said. “Phakic IOLs are an alternative for these patients, and there are several advantages. First, the lens is not removed and no corneal tissue is removed, and hence there is no chance for ectasia or corneal irregular astigmatism. Because we are retaining the corneal asphericity, this may preserve contrast sensitivity.”
Dr. Davis continued, “The disadvantages are those of intraocular surgery — damage to the angular endothelium, potential for pigment dispersion or synechiae and/or risk of infectious complication.”
Ranges of correction evaluated in the study were –5 D to –9 D (group A); –10 D to –15 D (group B); and –16 D to –20 D (group C). Dr. Davis said preoperative mean refractive spherical equivalent (MRSE) in group A was –8 D; group B was –12.5 D; and group C was –17.5 D. Twelve-month postoperative MRSE in group A was –0.51 D; group B was –0.53 D; and group C was –0.26 D, she said.
Refractive surgery day
The program on refractive surgery day was chock-full of presentations on developments in customized ablation. Most major laser manufacturers had updates on trials of their systems for individualized ablation.
Several presenters noted that customized ablation results are better using laser epithelial keratomileusis (LASEK) than with LASIK. Scott M. MacRae, MD, said LASEK has better results in higher-order aberrations than LASIK, possibly because of the differences in the biomechanics of the two procedures.
Marguerite B. McDonald, MD, updated her results with customized ablation using the Alcon LADARVision system. She said there was more gain in contrast sensitivity with customized treatment than with conventional treatment at 6 month follow-up. There was also less loss of contrast sensitivity contrast sensitivity with customized treatment than with conventional treatment at the same follow-up.
Dr. McDonald also provided an update on her gel-assisted LASEK technique, first described at last year’s American Academy of Ophthalmology meeting. In this procedure, a viscous material, (Genteal, CIBA Vision) is used to stiffen and loosen the epithelium, rather than the alcohol solution usually associated with LASEK.
Dr. McDonald has now used this technique in 42 eyes. She said that after her first eight patients, all patients had epithelial sheets successfully raised. She plans expansion of her pilot study, to include 100 eyes in 50 patients, with one eye undergoing LASIK and the other LASEK.
Personalize glaucoma treatments
Physicians should tailor glaucoma medication regimens to their patient as much as possible, according to a physician who spoke during presentations regarding glaucoma.
“There is a Chinese restaurant menu of glaucoma medications out there,” said Alexander Kent, MD. “You need to personalize the treatment.”
Dr. Kent advised attendees to scrutinize carefully which medications are best suited to the patient. “First of all, you need to figure out if the treatment is needed. Then identify the target pressure, initiate monotherapy and document its effect,” he said.
Dr. Kent said compliance is also a factor in evaluating which treatment is best, especially when the patient is on combination therapy.
“Consider the time it takes if patients are taking four medications. They’re taking a beta blocker four times per day; a prostaglandin once a day; an alpha agonist twice per day; and a carbonic anhydrase inhibitor three times per day … that can total to up to 1 hour and 10 minutes [to administer the medications] per day,” Dr. Kent said.
The physician should also consider the patient’s tolerance of the medication; if the patient has a physical disability such as Parkinson’s or Alzheimer’s disease; and the cost to the patient.
“Design a therapy that the patient can handle in all respects, and keep it simple,” he said.
Glaucoma’s aggression
Once a physician diagnoses glaucoma, the patient’s risk factors may not be important in determining how aggressive the disease is, according to Anne Coleman, MD.
Dr. Coleman discussed the epidemiology of glaucoma and its risk factors. Risk factors for glaucoma include increased intraocular pressure, age, race, family history, myopia, diabetes, systemic hypertension and migraine headache.
But Dr. Coleman said that these risk factors may or may not play a factor in the speed of the disease’s progression or the course of treatment.
‘Glaucoma nirvana’
Viscocanalostomy is a viable option in glaucoma management, according to Thomas Samuelson, MD.
“Do we need another procedure? Trabeculectomy is more effective and safer than ever,” he said. But the penetrating filtering procedure does have side effects, among them late bleb-related complications such as leaks and endophthalmitis.
“We need to reach ‘glaucoma nirvana.’ For pressure control without the bleb, viscocanalostomy can be an option,” he added.
Dr. Samuelson advised physicians to move forward cautiously in adopting viscocanalostomy, but he said interest in the procedure is increasing due to its success. Viscocanalostomy may have a more favorable safety profile, may result in fewer perioperative visits and fewer perioperative restrictions than trabeculectomy, he said.
‘Most misunderstood’ eye condition
In presentations involving external disease, Douglas Katsev, MD, said dry eye syndrome can be a “nightmare” for the ophthalmologist.
“Dry eye is the No. 1 repeated complaint by patients; the No. 1 misunderstood explanation as to why patients’ eyes need tears. And dry eye medications are the No. 1 eye medicine not taken as prescribed,” Dr. Katsev said.
He said the incidence of dry eye syndrome is increasing because of the aging of the baby boomers and the growth of the population of senior citizens. He also attributed the increase to the rise in the number of people undergoing LASIK surgery. He said this increase in the number of patients with dry eye adds to physicians’ frustrations.
Dr. Katsev said laser epithelial keratomileusis, or LASEK, can be an alternative to LASIK that may help to avoid postop dry eye syndrome. For patients with dry eye, he said, artificial tears and punctal plugs are treatment options.
Herpes simplex
Latanoprost does not induce reactivation of latent herpes simplex keratitis, according to a study presented here.
Y. Jerold Gordon, MD, presented data from a study conducted in a rabbit model. He noted that previously published studies have found an association between herpes simplex virus (HSV-1) keratitis and Xalatan (latanoprost, Pharmacia). Dr. Gordon studied whether Xalatan or its components (latanoprost and benzalkonium) prolong HSV-1 ocular shedding following reactivation of HSV keratitis.
In the study, rabbits were treated with formulations of benzalkonium with or without latanoprost 0.005%. Treatment with saline solution was used as a control. Dr. Gordon said there were no statistically significant differences among the groups in terms of the number of shedding days after reactivation.
Antibiotic treatment
Physicians need to be more sophisticated in assessing antibiotic effectiveness, according to James McCulley, MD.
Simply stated, “we need more data,” Dr. McCulley said.
Dr. McCulley presented information on human isolates of Staphylococcus epidermis and Staphylococcus aureus that were treated with Ciloxan (ciprofloxacin, Alcon) and Ocuflox (ofloxacin, Allergan). He said the post-antibiotic effects in the ciprofloxacin and ofloxacin cultures were equal.
“We need more data involving inhibitory quotients, time-kill curves and post-antibiotic effects,” he said. “Then we’ll know what drug we need and when.”
Dr. McCulley further stressed the need for standardization among these second-generation fluoroquinolones.
“If we can’t decide between this and that with these two drugs, then what will we do when we get to use” the fourth-generation fluoroquinolones gatifloxacin and moxifloxacin, he asked.
Generic drugs
Because use of generic drug formulations is increasing, physicians must determine whether the generic drug being prescribed is therapeutically equivalent to the brand-name drug, one researcher said.
“The main difference between the generic and brand-name drug may be in what makes them a solution,” John Wittpenn, MD, said. “Substitutions may occur without your knowledge, so you have to ask what is being prescribed,” he said.
In a small study, Pred Forte (prednisolone acetate, Allergan) was compared with generic prednisolone acetate. Patients underwent uncomplicated cataract surgery. Eleven days postop, among patients who received Pred Forte, 83% had only minor anterior chamber inflammation. Among the patients receiving generic prednisolone, 58% had 1+ or 2+ inflammation.
Quality of vision after LASIK
Postoperative outcome, preoperative refraction and pupil size are factors in predicting whether patients will have poor quality of vision after LASIK, although these factors can only partially explain symptoms, according to one presenter.
“We all know and have had patients in our practice that have quality-of-vision problems after LASIK,” said Steven C. Schallhorn, MD. “Although it doesn’t happen in very many folks, these patients can generally occupy or consume our practice.”
In an effort to identify predictive factors that may affect the quality of vision, Dr. Schallhorn and colleagues looked at a consecutive series of 100 patients. Patients were given a questionnaire preoperatively and at several postop intervals to gather information on glare, haze and halo disability.
Looking at the symptoms reported via the questionnaire and the postop results, the researchers found that “the uncorrected visual acuity (UCVA) result was very highly correlated with patient complaints.” UCVA was correlated with glare and halo complaints at 3 months (38% and 24% of variance, respectively) and glare complaints at 6 months (6%). Preop manifest spherical equivalent was correlated to glare symptoms at 6 months (23% of variance).
“Quality-of-vision problems are multifactorial,” Dr. Schallhorn said. “The No. 1 determinant is the postop outcome, in particular the UCVA; it co-varies with a patient’s postop refraction, so their lower order aberrations are significant. For every 4 D increase in preop myopia, we found a twofold increase in glare complaints. Pupil size had a very small influence, much smaller than we thought. No influence at 6 months, while we do see a small influence early on.”
According to Dr. Schallhorn, poor quality-of-vision symptoms can be only partially explained by these factors. “At best we can only explain 50% of the variability,” he said. He is now looking at higher-order aberrations in further study.
“This is a very important paper with two take-home messages,” said Richard L. Lindstrom, MD, moderator of the refractive surgery session at which Dr. Schallhorn presented. “Patients get better with time. Reassure your patients that the cornea continues to remodel even up to 12, 18, 24 months. Also, any patients with these symptoms who have residual refractive error, you should be a little more aggressive in your enhancements.”
See you next year
“The meeting was a spectacular success,” according to Dr. Lindstrom, who also served as a program co-director for the meeting. “The program was outstanding, and the attendance was near record levels. The venue, weather and receptions created an ‘aloha’ atmosphere that was appreciated by all.”
According to Richard N. Roash, executive vice president of SLACK Incorporated, “This meeting provides a unique opportunity for physicians to hone their skills, while also allowing them the opportunity to build relationships with other physicians and industry professionals.”
Plans are already under way for Hawaii 2003, which returns to Maui and the Grand Wailea Resort and Spa, Jan. 19-24, 2003. See below for registration details.
Look for more coverage of Hawaii 2002 in upcoming issues of Ocular Surgery News. Also watch the OSNSuperSite.com for daily ophthalmic news coverage.
For Your Information:
- Hawaii 2003 returns to Maui at the Grand Wailea Resort and Spa, Jan. 19-24, 2003. To register or for more information, contact Meeting Registration, SLACK Incorporated, 6900 Grove Road, Thorofare, NJ 08086; (856) 848-1000, fax: (856) 848-6091; meetingregistration@slackinc.com.