This month’s article will recap some of the highlights of Hawaiian Eye 2017. This year’s meeting was held on the beautiful island of Kauai at the Grand Hyatt in Poipu. The setting was amazing and the company was fantastic.
Below are a few lessons learned from speakers in various subspecialties.
Retina
Jack Wells, MD, spoke about Genentech’s Lucentis® prefilled syringe. This syringe was FDA approved in October 2016 and consists of 0.5mg of ranibizumab indicated to treat patients with wet age-related macular degeneration (AMD), macular edema after retinal vein occlusion, and myopic choroidal neovascularization. This is the first anti-VEGF to be approved for myopic CNV and is now available in the U.S.
Allen Ho, MD, discussed the advantages of home monitoring systems for detecting early AMD progression. Traditionally patients used the Amsler grid. Now there are new devices, such as cell phone apps (i.e. Digisite) and home devices (i.e. ForseeHome™ — now has Medicare approval and reimbursement) that allow patients to monitor central vision and detect changes early, which will allow the patient the potential for better outcomes. The use of home monitoring is especially important for those at greatest risk, such as those with fellow eye disease (advanced AMD in one eye).
Ocular Surface
John Sheppard, MD, spoke about neurostimulation for the treatment of dry eyes. The device is patient driven, pain free, can be used as many times as the patient wants, and is not associated with any known side effects. This neurostimulator device is placed into the nasal passage and when activated, stimulates the trigeminal nerve, which triggers the lacrimal nerve and gland. The device is not currently available, but hopefully will be on the market in the next couple of months.
Cynthia Matossian, MD, discussed the importance of patient and staff education for the treatment of dry eye disease. She discussed her dry eye algorithm, including what type of testing is appropriate, who administers the testing and what type of treatment she selects depending on where the patient is on the continuum of dry eye disease. Patients are often not adequately educated on the fact that dry eye disease is chronic and that they will need to be on treatment forever. Staff must be empowered to ask the appropriate questions to the patients so that certain tests can be done prior to starting therapy. Once that data is obtained, treatment options can be expanded and a more aggressive approach can be used if necessary.
Cornea
Raj Rajpal, MD, spoke about the widening scope of potential uses for corneal collagen cross-linking. Collagen cross-linking was U.S. FDA approved in April 2016 for progressive keratoconus. Following that, the FDA approved its use for corneal ectasia after refractive surgery in July 2016. Both approvals were based on studies showing a decreased Kmax. Evidence from outside of the U.S. show epithelial-on treatments, accelerated treatments, pulse treatments and customized treatments that are being performed for keratoconus. These procedures are currently being tested in the U.S. Photorefractive intrastromal cross-linking (PIXL) studies are being performed outside the US as well. This technology is used to correct low levels of refractive error (0.75 – 1.25 D of low myopia). There is promise for this technology for the treatment of astigmatism, hyperopia and presbyopia.
Francis Price Jr., MD, talked about DMEK providing better visual results and less rejections when compared to other types of transplants. Really good OCT has helped surgeons to see the tissues and watch the fluid mechanics. Additionally, it allows one to see which way the tissues are oriented, eliminating the need for other instruments that were previously used for this detection. There is a new punch that has a stop on it to prevent full thickness incisions through the donor tissue. There are also new ways to score the tissue and many are using the trifold technique in hopes of having less cell loss during introduction of the tissue and ease of unfolding during the procedure.
Cataract
Nicoletta Fynn-Thompson, MD, talked about how to preserve the endothelium and manage corneal edema during cataract surgery. Three scenarios were discussed. With corneal decompensation, it is important pre-operatively to assess, educate and plan surgical techniques to decrease corneal edema post-operatively. She discussed intraoperative techniques and post-operative management of corneal edema, such as the use of sodium chloride drops. If that doesn’t work, then proceed with endothelial keratoplasty.
Descemet’s membrane detachment leading to corneal edema was also discussed. Peripheral detachments can heal on their own spontaneously, however if central, a desmetopexy is recommended with injection of air or gas. Lastly, she discussed corneal edema from a retained lens fragment. This edema is often found on the inferior cornea and fragments can sometimes only be seen by gonioscopy. Management is surgical removal.
Kendall Donaldson, MD, presented a talk on pupillary miosis during femtosecond laser assisted cataract surgery, and compared four different laser platforms and traditional cataract surgery. In her study, she measured pupillary size before and three minutes after the application of femtosecond laser for the capsulotomy. It has been shown that the release of prostaglandins during the capsulotomy is what is leading to pupillary miosis.
When comparing the different platforms, she found that the LenSx® unit created more miosis than the Catalys® and Victus lasers. Also, patients with lighter irides experienced a greater degree of miosis and patients who have floppy iris syndrome, glaucoma and a history of previous intraocular surgery were also at higher risk for miosis.
Donaldson looked at prostaglandin samples from the patients and found that the miosis was not related to the IOP increases during surgery. Interestingly, it is not just the prostaglandins that are responsible for miosis, as many of the traditional cataract patients had higher levels of prostaglandins. Also, some patients who only had docking of the laser experienced more miosis.
Glaucoma
Yvonne Ou, MD, spoke about how changes in lifestyle can help lower IOP in glaucoma patients. Increasing exercise and consuming more dietary nitrates, such as fruits and vegetables, especially green leafy ones can help. She discussed how studies have showed associations between certain lifestyle behaviors and changes in IOP. For instance, those who exercise less had worse visual fields. Interestingly, those who were sedentary but then became active had greater IOP reductions than those who already exercised regularly.
Ian Conner, MD, spoke about how the stab incision reduces the time of trabeculectomy. This procedure can be shortened to less than 10 minutes. The procedure uses a single blade incision approximately a 3mm keratome that is inserted into the eye through the conjunctiva, through a scleral tunnel, entering the anterior chamber 0.5 to 1mm anterior to the limbus. A 1mm trabeculectomy punch to make two to four punches titrating to flow, followed by closure of the conjunctiva. The advantage of this technique is that it simplifies and shortens the procedure. Disadvantages include limited titratability, although there are ways to get around this issue.
The talks mentioned above are only a handful of the excellent talks that were given at this year’s meeting. I encourage all of the readers to consider coming to this meeting in 2018, as nothing is better than being there live!
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