Hawaiian Eye is one of the largest ophthalmology meetings in the nation, catering to ophthalmologists of all subspecialties, as well as nurses and administrators. It offers a wealth of information covering the spectrum of the eye, including retina, cornea, glaucoma and oculoplastics. This year the meeting was held on the beautiful island of Kauai at the Grand Hyatt.
The typical day at Hawaiian Eye starts bright and early at 6:30 a.m. with a breakfast seminar. The General Session runs from 7:30 a.m. to 12:45 p.m. There are various lunch seminars for physicians from 12:45 – 1:45 p.m., followed by workshops for all programs from 2 – 4 p.m.
One unique feature of the meeting is the CME Banyan Tree sessions from 5 – 6 p.m. Those who choose to join the faculty can enjoy a beer while sifting sand through their toes watching the sunset over the Pacific Ocean. This is a great opportunity for small groups to bring their questions and experiences to discuss with the experts.
Below are some of the highlights from year 2014.
OCULOPLASTIC SYMPOSIUM
Wendy W. Lee, MD, Femida Kherani, MD, Jeremiah Tao, MD, Vikram Durairaj, MD, Joely Kaufman, MD, Steven Yoelin, MD
The Oculoplastics Symposium was the kick off to Hawaiian Eye again this year. Attracting an impressive and growing crowd, the program covered a variety of functional and cosmetic topics.
Eyelid trauma, eyelid lesions, and eyelid malpositions were discussed in the first half of the meeting. Basic recognition patterns and repair mechanisms appropriate for the general ophthalmologist were covered. The second half of the symposium was dedicated to aesthetics. A discussion of the aging process and ideals of beauty started the afternoon.
Next, I gave a talk on techniques in upper eyelid blepharoplasty. The salient points being to recognize true dermatochalasis and differentiate between that and brow ptosis and ptosis. Know your anatomy, be conservative, and know how to avoid and potentially treat the complications, including hemorrhage, cautery fire, asymmetry, and lagophthalmos.
Botulinum toxins and dermal fillers were then discussed; including all of the currently available FDA approved products. Proper evaluation and injection techniques were learned, as well as potential complications.
After the talks, a ‘Rapid Fire Injection Pearls Panel was held with all of the speakers. Various faces were flashed up on the screen and an open discussion pertaining to evaluation of the patient and treatment options and concerns was held. The symposium closed with the live injection workshop where various patients were injected on stage to demonstrate the myriad of FDA approved injectables. Different areas of the face were covered and attendees were given the chance to openly ask questions.
Below are a few pearls from the oculoplastics session.
Eyelid Lacerations – Femida Kherani, MD
Dr. Kherani discussed the usefulness of monocanalicular stents in eyelid laceration repairs. Keep a Mini-Monoka in your on call bag because it is easy to use in a minor OR setting. A newer intubation device, the Masterka, has a Bowman probe style-inserting device to help placement of the stent in the case of strictures.
Aesthetics: Live Injection Workshop – Joely Kaufman, MD
Dr. Kaufman discussed how to differentiate between the male and female face and how to use different techniques to shape the periocular area. Two of the newer fillers on the market, Belotera and Voluma, both have unique applications. Voluma is the first FDA approved product for the midface/cheek area.
Lower Eyelid Malposition – Jeremiah Tao, MD
Dr. Tao covered both complex and simple eyelid malpositions, which are both important for all ophthalmologists to be familiar with. Included in his talk were videos of various surgical procedures to fix these malpositions.
NEURO-OPHTHALMOLOGY
Please Stop Using PERRLA When Examining Patients for Neuro-Ophthalmic Conditions – Andrew G. Lee
Dr. Lee requested that we abandon the use of PERRLA because this only tests the parasympathetic function of the pupil in light and accommodation. The pupil needs to be evaluated in light and dark and swinging the flashlight so conditions like anisorcoria, associated with Horner’s Syndrome, are not missed.
CORNEA
The Role of the Posterior Corneal Surface in Surgical Planning – John A. Hovanesian, MD
Dr. Hovanesian recommended that we take into consideration the posterior corneal surface in surgical planning. Many people have unrecognized ‘against the rule’ astigmatism and are undercorrected for this.
Newer NSAIDs: Anesthetics, Analgesics, Both? Does it Matter? – John R. Wittpenn, MD
Dr. Wittpenn investigated whether the 2 newer NSAIDS, Bromfenac and Nepafenac, have the same anesthetic effect that the older NSAIDS, Diclofenac and Ketorlac, had in the past. They used the same study model that was used with the original study using the Cochet-Bonnet esthesiometer and found that the newer agents had significantly less reduction in corneal sensitivity as compared to the older agents.
Evaluating Macular Structure and Function Before Multifocal IOL Implantation – Kevin M. Miller, MD
Patients who undergo cataract surgery with a multifocal IOL tend to have high expectations. It is ideal if outcomes are greater than expectations. In these particular patients, careful evaluation of the macular structure is key. Take caution and/or avoid multifocal IOL implantation in patients with retinal vascular disease, cystoid macular edema, advanced glaucoma, optic nerve pathology, epiretinal membranes or vitreous traction. Many epiretinal membranes are hard to identify, so a high resolution OCT may be helpful. Tips for evaluation of a multifocal IOL patient include a 90D exam, high resolution OCT, fluorescein angiography and an evaluation by a retinal specialist.
Update on a Presbyopia-Correcting Toric IOL– Jay S. Pepose, MD, PhD
Dr. Pepose discussed the Trulign Toric IOL, a toric modification of Crystalens AO. This is a biconvex silicone lens that is FDA approved for the correction of post-operative refractive astigmatism. Updates of this lens include a new outdoor UV protection and aspheric, zero aberration optics. Alternatives to correcting astigmatism include incisional surgery and laser surgery. The toric IOL lessens the risk of dry eyes, corneal denervation and wound healing.
Corneal Shield Speeds Visual Recovery After PRK, LASIK – Marguerite McDonald, MD
After PRK or LASIK, patients go through a period of up to 4 or more days to recover functional vision. Refraction varies due to edema induced curvature changes, flap-interface, and irregularities leading to poor optical clarity. To prevent this, Dr. McDonald uses the Nexis cornea shield, which is not currently commercially available in the US. This shield has a rigid optic, does not move with blinking and is water impermeable and oxygen permeable. It provides a smooth optical surface and minimizes edema. This allows faster visual and functional recovery compared to conventional LASIK without a shield.
Surgeon Discusses Diagnosis and Management of Conjunctival Tumors – Helen K. Wu, MD
The diagnosis of conjunctival tumors is traditionally made with an excisional biopsy. Management mainstay is using topical chemotherapy or immunotherapy to debulk or treat residual tumor. The most widely used agent is mitomycin C, but this can be very irritating to the ocular surface. This drug is more tolerable when used in weekly cycles. Alpha interferon is less toxic but more expensive. This drug is compounded and is very effective in squamous neoplasias. Surgically, the Shields’ have described a ‘no touch’ technique involving removing the tumor from the corneal side first, followed by the conjunctival side with a wide excision. Reconstruction can be by primary closure or with an amniotic membrane graft with adjunctive chemotherapy or immunotherapy. Results with squamous neoplasia have been good. Close follow up is essential.
RETINA
Chronic Central Serous Chorioretinopathy – William F. Mieler, MD
The definition of chronic central serous chorioretinopathy is persistence of disease beyond 3 months. The acute phase involves thickening of the choroid, but thinning after time does not necessarily mean resolution of the disease. The usefulness of PDT and ICG in the diagnosis and management of chronic CSCR, especially in cases with plaques, was discussed. With this disease, persistence of fluid affects the health of underlying retinal pigment epithelium. This disease can also lead to a bullous detachment for unknown reasons. Although etiology is unknown, some of these chronic cases can relate to endogenous cortisol elevation. Many other treatments were reviewed, but the bottom line is that photodynamic therapy at reduced fluence offers the best results with improved OCT and is the treatment of choice amongst many.
Recognizing OCT Artifacts Critical in Quantitative Analysis – Jay S. Duker, MD
When doing qualitative analysis using OCT, artifacts are not that important. But when you are doing quantitative analysis (nerve fiber layer), recognizing artifacts is critical because the quantitative data will not be accurate if the software breaks down. There are measures you can take to confirm that OCT images are adequate. Look at whether the segmentation lines are where they should be on the ILM and RPE if doing full retinal thickness and ILM and outside the nerve fiber layer if doing nerve fiber layer thickness.
GLAUCOMA
Eyes With Glaucoma Tubes or Filters at Higher Risk of Corneal Graft Rejection – Francis W. Price, MD
There were 3 main points from this talk:
- With standard full thickness PKs, glaucoma is a risk factor for increased failure from rejection, endothelial problems and ocular surface disease.
- With endothelial keratoplasties, people with pre-existing glaucoma have very good visual recovery, and no increased risk of rejection or endothelial failure except…
- When patients have filters or tubes, they have a dramatically increased chance of graft failure in first few years after surgery, regardless of whether it is a full thickness graft or endothelial keratoplasty. There appears to be a blood-brain-aqueous barrier breakdown possibly accounting for endothelial cell weakness.
Function May Not Follow Structure in Glaucoma Evaluation – Joel S. Schuman, MD
The common conception that function follows structure may not be correct. In the early part of glaucoma, there is structural damage (nerve fiber layer thinning, loss of optic nerve tissue), and then you hit a tipping point of visual field abnormalities that happen at the same time as structural changes. The structural changes then bottom out and stabilize, but function continues to get worse. Early structural change is real change, so it is important to diagnose and treat early in the disease. As well, it is important to realize that advanced disease may not be stable, even though structure stabilizes.
Early → structural change before VF loss. Later → VF loss when structure is stable.
GENERAL
Physicians Should Prepare for Intended and Unintended Consequences of Sunshine Act – Alan E. Reider
Intended Consequences: The act will assure transparency of physicians’ relationships with industry, provide patients with information to make informed choices about their physicians, and provide a deterrent effect for abusive relationships between physicians and industry.
Unintended Consequences: Information may be available, but it will not be understood and it may be abused. There will be errors and more investigations triggered by the data supplied. To mitigate unintended consequences, ensure that data reported is accurate and be compliant. Prepare patients by educating them on relationships with industry.
There were so many fantastic and noteworthy talks at this year’s meeting, of course too numerous to recount in this short article. My advice is to see them all for yourself by not missing next year’s meeting, which will be held at the Grand Wailea on Maui. Aloha!