New York meeting updates clinical topics

NEW YORK – Over the course of 2 days, surgeons at a meeting here heard presentations on “the cornerstones of most anterior segment surgeons’ practices” – cataract, glaucoma and refractive surgery – from world-renowned colleagues.

Those were the words of Richard L. Lindstrom, MD, Chief Medical Editor of Ocular Surgery News, welcoming attendees here to the Ocular Surgery News Symposium on Cataract, Glaucoma and Refractive Surgery.

“It is my honor and pleasure to welcome you to New York,” said Dr. Lindstrom, program chairman for the meeting. “This is one of several meetings that we at OSN do throughout the world. You can look at the Royal Hawaiian Eye Meeting, the new glaucoma meeting in Las Vegas and our annual meeting in Italy, which includes live surgery.”

The two-day meeting comprised several symposia, including one on new technology moderated by Robert H. Osher, MD; OSN Compliance Case Studies, with topics solicited by meeting registrants, moderated by Alan E. Reider; and an update on the pharmacology of age-related macular degeneration by Jorge G. Arroyo, MD.

In addition, keynote presentations by Edward E. Manche, MD, and Richard P. Wilson, MD, and Steven C. Schallhorn, MD, focused on surgical prophylaxis, compliance in glaucoma patients and LASIK in aviators, respectively.

“We have a jam-packed program and lots of good information,” Dr. Lindstrom told the more than 300 attendees from throughout the United States and Canada.

At the conclusion of the meeting, Dr. Lindstrom commented, “This meeting included some great sessions, and I am glad it included controversial topics.”

The meeting, through its sponsor, SLACK Incorporated, publisher of Ocular Surgery News, offered participants an opportunity to earn 10.5 hours of category 1 credit toward the AMA Physician’s Recognition Award. Attendees were also afforded the opportunity to attend one of eight afternoon workshops and visit the exhibit hall.

Following are highlights of this year’s meeting. Many of these items appeared first in live coverage of the meeting on OSNSuperSite.com. Look for expanded coverage of some of these topics in future issues of Ocular Surgery News.

CATARACT

Fluoroquinolone penetration

An antibiotic prophylaxis regimen started on the day before surgery does not result in significantly greater aqueous penetration than a dosing regimen started on the day of surgery, according to a study presented here.

Edward E. Manche, MD, discussed the first results of a small study conducted by Stephen S. Lane, MD, and Samuel Masket, MD.

“This is very important research that is being done,” said Dr. Manche, describing the study in which the surgeons randomized two groups of 30 patients each to receive moxifloxacin in different dosing schedules.

Group 1 received four doses of topical moxifloxacin on the day of surgery. Group 2 received same dosing schedule on the day of surgery but also received four doses of moxifloxacin the day before surgery. Aqueous samples were taken to determine levels of drug penetration.

“Both groups had excellent penetration into the aqueous. The group that received four doses the day before surgery were slightly better, but not significantly so. And what is really important is, if you look at the MIC (minimum inhibitory concentration) for Staphylococcus aureus, it far exceeds what is needed,” Dr. Manche said.

Cell loss with AquaLase, ultrasound

AquaLase and conventional ultrasound caused similar levels of mean endothelial cell loss in a laboratory setting, according to Kerry D. Solomon, MD. There was no statistically significant difference in levels of mean cell loss in a cadaver eye study he described here.

“One of the things that concerned us with the new waterjet technology was the potential for endothelial cell damage,” Dr. Solomon said.

In his study, Dr. Solomon randomized 20 fresh human cadaver eyes to undergo either standard ultrasound with the Alcon Legacy or an AquaLase procedure with the Alcon Infiniti system. The age, nuclear density and ophthalmic viscosurgical device used were similar between the two sample groups, Dr. Solomon said. None of the eyes had undergone previous intraocular surgical procedures.

Corneal buttons were removed immediately following the procedure and stained.

The cornea was divided into five areas: central, superior, inferior, nasal and temporal. Dr. Solomon then calculated the amount of endothelial cell damage in each using light microscopy.

“When we looked at mean cell death, as well as cell death in individual areas, there was essentially no difference between what we found in the laboratory with AquaLase (60.2 mm²) and conventional ultrasound (60.4 mm²),” Dr. Solomon said.

GLAUCOMA

Patient responsibility

Physicians should empower glaucoma patients to take care of their own visual health, according to Richard P. Wilson, MD. Getting the patient involved may help improve compliance, he said.

“You need to link compliance to their core values,” said Dr. Wilson in his keynote address. “You need to tell the patient that if they take their drops, then they will be able to pick up their grandchildren after school, so their son or daughter can go to work.”

Noncompliance with medical treatment is perhaps the biggest challenge in glaucoma patient management, Dr. Wilson noted.

As an example of how noncompliance with treatment can be a serious impediment to visual health, Dr. Wilson cited the results of a patient survey. The research showed that 25% to 40% of patients who turned in a glaucoma prescription at a pharmacy never picked up the medication. Further, among patients who started taking a prostaglandin for the first time, only 40% finished the year taking the medication. As few as 24% of patients started on other medications complied for the full year. In patients already on other glaucoma medications, only 64% finished the year taking a prostaglandin, and less than half (44%) complied with their dosing regimen for other medications.

Dr. Wilson explained that prescribing more powerful medications and increasing the use of topical combination therapy will provide better control with fewer drops, which will increase quality of life and improve compliance.

He added that the physician should spend more time counseling patients on general health issues such as exercise and smoking cessation.

‘Better operation’ needed

Glaucoma should be considered a “surgical disease” more often, according to one physician. But for this to happen, better glaucoma surgical options are needed.

Lack of patient compliance and the costs of taking topical glaucoma medications are good reasons why surgery should be considered more often as an option in treating glaucoma patients, according to Reay H. Brown, MD.

However, Dr. Brown said, most current surgical procedures involve too many risks to be performed routinely early in the disease course. Additionally, Dr. Brown said, at 5 years postop the success rate of most glaucoma surgical procedures ranges from 40% to 75%. There is also continuing risk of infection, hypotony and failure.

The advantages of newer medical therapies include fewer side effects and the ease of explaining the treatment to patients. But Dr. Brown said the disadvantages include patient discomfort, cost, lack of compliance and poor long-term efficacy.

Dr. Brown said that “hopefully, new surgical technologies” will soon present better treatment options for patients.

REFRACTIVE SURGERY

LASIK for Navy aviators

Wavefront-guided LASIK is preferred over conventional LASIK for Navy aviators because of the higher quality of postop vision, according to a Navy surgeon.

There is “a lot of need for this right now,” said Steve C. Schallhorn, MD, director of cornea and refractive surgery at the Naval Medical Center in San Diego. He presented one of the keynote addresses at the meeting.

Dr. Schallhorn said conventional LASIK cannot be performed in Navy pilots because of “the significant lowering of the quality of vision. Flap stability in conventional LASIK is not a show-stopper,” he said.

Wavefront-guided LASIK induces fewer aberrations, thereby improving quality of vision for patients, he said.

He added that photorefractive keratectomy would be preferred over wavefront-guided LASIK, but there is a greater interest in LASIK because the patient can return to flying more quickly. He suggested that clinicians undertake studies of wavefront-guided PRK in pilots.

Diagnostic tools lacking

The measurement and documentation of glare and pupil size in refractive surgery may raise legal concerns for surgeons, said Louis E. Probst, MD.

“This is a controversial area. The more I investigate this issue, the more I realize that there is very little we understand,” Dr. Probst said. The potential for legal action against the surgeon as a result of poor documentation of glare and pupil size is a grave concern, he said.

“The first problem is that measuring pupils is critical, in that optical zone and blend zone is programmed based upon pupil size,” Dr. Probst said. Surgeons must determine the correct optical zone and blend zone given a particular pupil size, and the variety of available devices give different results, he said.

In addition, he said, clinicians must pay closer attention to the terminology they are using.

“The terms glare, glare disability and contrast sensitivity have been used very loosely, meaning different things often not well-defined by various authors,” Dr. Probst said.

Other issues include the lack of a gold standard of testing for glare, the lack of an objective test for glare, and the lack of evidence in the literature confirming a relationship between pupil size and glare.

Dr. Probst concluded that malpractice claims based upon pupil measurements are a risk; terms and standard tests must be defined; and there is a clear need for studies to define the relationships among glare disability, pupil size, aberrations and wavefront measurements.

REFRACTIVE CATARACT

Accommodating IOLs

Since the C&C Vision CrystaLens received a recommendation for Food and Drug Administration approval with conditions in May, one surgeon said he is “looking forward to implanting more of these” lenses.

Mark Packer, MD, presented the FDA trial results for the lenses. Dr. Packer said the lens is under expedited review by the FDA, and final approval should come “soon.”

Dr. Packer said unlike multifocal lenses, which are characterized by a reduction of contrast sensitivity and an increase in glare, the CrystaLens shows contrast sensitivity improvement without glare.

He said in FDA studies the lens has shown “excellent visual outcomes” at distance, intermediate and near. He added that the accommodative effect seems to increase over time and is not affected by YAG capsulotomy, age, axial length or IOL power.

“Patient satisfaction also is high,” Dr. Packer said.

Light Adjustable Lens trials

U.S. trials of the Light Adjustable Lens will begin in 2004, according to the lens’ developer.

Daniel M. Schwartz, MD, said that the lens, manufactured by Calhoun Vision, has a 4 D range of adjustment and should be able to correct myopic, hyperopic and astigmatic errors.

In vitro and animal studies demonstrated the ability to perform precise adjustment of myopic and hyperopic errors in the lens with no leaching of macromers, Dr. Schwartz said. In human trials conducted in four eyes, the lenses were well tolerated and biocompatible at 6-month follow-up.

Dr. Schwartz said the adjustment of lens power is easy for both doctor and patient.

AcrySof Toric results

The AcrySof Toric IOL can “significantly reduce” cylinder and improve uncorrected visual acuity in patients with corneal astigmatism who are undergoing cataract surgery, according to one surgeon.

Stephen S. Lane, MD, presented data on 77 patients who were implanted with the toric version of Alcon’s acrylic IOL.

Patients were randomly assigned to receive the Alcon AcrySof Toric (SA60TT) or a control nontoric lens (AcrySof SA60AT). At 80 to 100 days postoperative, 78% of patients implanted with the SA60TT were 20/20 or better uncorrected, compared to 68% of patients implanted with the SA60AT.

No lens-related adverse events were reported, Dr. Lane said. Nonlens-related adverse events reported with the SA60TT included iris damage due to IOL exchange (one patient); cystoid macular edema (three patients); and secondary surgical intervention (two patients), which included laser to repair retinal hole and an anterior chamber paracentesis to lower intraocular pressure. In patients implanted with the SA60AT, nonlens-related adverse events included cystoid macular edema (one patient) and secondary surgical intervention (one patient), which included removal of retained lens fragment.

Dr. Lane said the toric lens is undergoing further clinical analysis to demonstrate safety and effectiveness.

Discern the cause of droopy eyelids before making treatment decision

NEW YORK – Brow ptosis is one of the most commonly misdiagnosed conditions, but looking at the cause of droopy lids could change that, according to a surgeon speaking here. “For a lot of patients and most of my referring physicians, droopy eyelids are viewed as and treated by blepharoplasty. And I’d like to change that perception,” said Ron W. Pelton, MD, PhD, here at the Ocular Surgery News Symposium on Cataract, Glaucoma and Refractive Surgery. “When you are considering a brow lift, first look at the differences between the male and female brow, which have specific characteristics,” he said. Dr. Pelton also suggested surgeons look for factors that may or may not allow one to hide a brow lift. That is, observe the patient’s forehead position and appearance and the type of brow hair, and determine whether previous surgery due to trauma has been done. Dr. Pelton described his rules of thumb when deciding whether a brow lift should be done. “If your upper incision is going to be within 10 mm of the brow, consider a brow lift. Also, if you have a patient with significant lateral hooding, who has had a past cosmetic blepharoplasty and ‘wants more taken off,’ or who has a paretic brow, consider a brow lift,” he said. “We all know about brow ptosis, and I promise you, if you look for it you’ll see it. And hopefully when you see it, you’ll correct it,” Dr. Pelton said.

For Your Information:

• The Ocular Surgery News Symposium on Cataract, Glaucoma and Refractive Surgery was held Sept. 20-21, 2003, in New York. The CME activity was sponsored by SLACK Incorporated, publisher of Ocular Surgery News. Next year’s meeting will be held in New York, Sept. 11-12.