Hawaiian Eye 2016 was another epic meeting located on the big island of Hawaii at the Hilton Waikoloa Hotel. Again, the meeting attracted numerous eye care specialists, administrators and nurses from every discipline. The program was filled with interesting talks given by well-known faculty from around the country. Below are some of the highlights.
Medical Retina
Dr. Michael Ip described the advantages of anti-VEGF therapy in patients with proliferative diabetic retinopathy. There is good anecdotal evidence to support the use of this medication and how it can decrease macular edema secondary to this disease. Secondary outcomes data from other clinical trials show a positive response with regression of proliferative diabetic retinopathy in patients treated with anti-VEGF therapy. Protocol S from the Diabetic Retinopathy Clinical Research Network shows that the use of anti-VEGF therapy is non-inferior to pan-retinal laser photocoagulation. There was also a reduced need for vitrectomy and fewer visual field defects in the anti-VEGF group. Overall, there is mounting evidence, including anecdotal evidence, secondary outcomes data from other clinical trials and level 1 evidence from randomized controlled trials that indicate a paradigm shift toward anti-VEGF therapy as opposed to pan-retinal photocoagulation.
Cataract
Dr. Audrey Talley Rostov spoke about different types of intracameral antibiotics for the prevention of endophthalmitis after cataract surgery. She recommends routine use of intracameral cefuroxime and moxifloxacin, but cautions against routine use of intracameral vancomycin, which can lead to the rare complication of hemorrhagic occlusive vasculitis.
Anterior Segment/Cornea
Dr. Thomas John spoke about the multiple uses and advantages of amniotic membrane. Amniotic membrane acts as an anti-inflammatory, an anti-scarring, pro-wound healing, and stem cell expansion supporting material. It is useful for many things, such as persistent epithelial defects, post-infectious ulcers, in inflammatory conditions such as Stevens-Johnson syndrome, and to reconstruct the ocular surface (post pterygium surgery, leaking bleb, etc). There are many available forms on the market now, including Prokera, which is easy to apply in the office setting. Prokera can be used as a single sheet or in multiple layers for perforations. It has been found that amniotic membrane promotes nerve regeneration for improvement of symptoms in dry eyes as well.
Ocular Surface
Dr. Frank Bucci revealed data on oral re-esterified omega-3 supplements and dry eyes. 105 patients were randomized to receive 4 capsules of PRN Omega Health Dry Eye Omega Benefits (54 patients) or a placebo consisting of 4 capsules of safflower oil (51 patients). Dry Eye Omega Benefits contain a 3:1 combination of 1680 mg of EPA and 560 mg DHA, a ratio thought to help dry eye more than other ratios. Data showed a mean tear osmolarity decrease of 10 mOsm/L in the treatment group and 8 mOsm/L decrease in the placebo group from baseline to a 12-week follow up. The ocular surface Disease Index score from baseline to 12 weeks showed a mean change of -17 in the treatment group and -5 in the placebo group. Mean tear break up time increased 3.47 seconds in the treatment group and 1.20 seconds in the placebo group during the same time frame. Regarding MMP-9, 43% of patients in the treatment group tested positive at baseline. This percentage dropped to 20% in the treatment group at week 12. In the placebo group, 32% tested positive at baseline and 30% of the placebo group tested positive at the 12-week follow up. The omega index increased from 4.19% to 7.19% in the treatment group and from 4.9% to 5.14% in the placebo group during the follow up period.
Refractive Surgery
Dr. Rajesh Rajpal spoke about the promises of collagen cross-linking in keratoconus and post-LASIK ectasia. The procedure is done with the epithelium off and a 30-minute riboflavin soak time followed by a 30-minute treat time with UV light. Accelerated treatments also have been done with the epithelium on. Patients with keratoconus had an approximately 2.6-diopter difference in the flattening effect with cross-linking versus patients who did not have treatment. In patients with post-LASIK ectasia, there was about a 1.7-diopter difference in those who had cross-linking versus those who did not. International data suggests that the flattening effect can be present for up to four years. Hopefully this data will lead to FDA approval in 2016.
Glaucoma
Dr. Kuldev Singh discussed normal tension glaucoma (NTG) and whether it should be considered a distinct disease entity from primary open angle glaucoma. He states that the fundamental approach to patients with normal tension glaucoma is the same as that of primary open angle glaucoma, so it probably shouldn’t be considered a different disease. That being said, there are certain challenges with NTG as it is harder to lower a normal pressure than it is to lower an elevated pressure.
Oculoplastic Surgery
I gave a talk on eyelid lesions: diagnosis and management. Characteristics of benign lesions include a well-outlined lesion with no loss of normal architecture. Characteristics of malignant lesions include irregular borders, a pearly, sometimes ulcerated surface with telangiectasia’s and loss of normal architecture. Excision for a presumed benign lesion should be excisional, whereas biopsy for a presumed malignant lesion can be handled in various ways. It can be excised with permanent section, which has advantages of a single procedure if the margins are clear. It can be excised with frozen section, which pretty much ensures clear margins, but can be timely and costly, or a team approach with a Mohs surgeon can be used, requiring 2 surgeons, but a minimal excision. Reconstructive options vary, from primary closure to flaps and grafts. The most important aspect to consider when reconstructing the eyelid is to replace this bilamellar structure with vascularized tissue while maintaining the function of the eyelid, which is to protect the globe.
Above are just a few of the highlights from Hawaiian Eye 2016, covering many of the subspecialties. There was much excitement during the meeting around these topics, some novel and new, and some old standards. Stay tuned for additional reports from this fabulous meeting.