CAKE & PIE POST (AAO 2020 Virtual Edition) - Issue 2

Opening Day Jackpot

by Brooke Herron

It’s finally here: The American Academy of Ophthalmology (AAO) 2020 Virtual annual meeting. And while we all wish we could be together in Las Vegas with this jackpot scientific program, the odds are still in our favor — new data, products, surgical techniques and discoveries will be shared, albeit from the comfort of our own homes and offices.

For many ophthalmologists, this year has been more difficult than years past: The COVID-19 pandemic has shuttered clinics and changed business practices around the world. However, if the attitude from the opening ceremony is any indication, the ophthalmic community is nothing but resilient.

To take an inside look at the varying impacts of the pandemic, the AAO Executive (AAOE) Opening Session, titled From Recovery to Resilience: Create a Thriving Practice Post-COVID-19, covered topics affecting ophthalmic practice management today, including leadership, financial strategies for the COVID-19 era, and what’s on the horizon with practice consolidation.

Playing roulette in 2020

“What a year we’ve just been through. Little did we know that at last year’s annual meeting, we all should have attended the course on disaster

planning,” began AAOE Board Chair Joanne Mansour, OCSR.

Indeed, many practices are now dealing with issues that couldn’t have been imagined last year: acquisition of PPE,

DEFINITION

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When you and your coworker are in the same office on a Zoom call and you hear them on your headset do something after you have already seen them do it physically.

Example: I saw my coworker squirt ketchup on their hotdog before I heard it on my headset–what a sonic zoom!

*New

definitions, by Media MICE

Bets are in, and AAO 2020 Virtual looks to be a winner

HR issues related to staff furloughs, lean practice flow… and so on.

“The Academy staff observed all this and took action and assembled the AAOE practice recovery taskforce,” said Mansour. Comprising Academy leadership, members and staff, the team provided tools for struggling practices to continue operations; organized webinars with guidelines on new changes, as well as provided insight into new telemedicine billing practices.

Mansour further commended the AAOE for their support during the pandemic and expressed the thoughts shared by many: “It’s disappointing that we can’t meet in person this year . . . the annual meeting is always such a wonderful time of networking and bonding over this passion for eyeballs that we all share.”

Betting on culture and leadership

The main speaker for the first part of this session was Dr. Ruth Williams, who discussed the importance of cultivating culture and resilient leadership.

“Ophthalmology practices have guiding principles, and these were particularly tested during the COVID pandemic,” continued Dr. Williams, noting that the Academy recommended ophthalmologists cease providing care, except in emergency situations on March 18, 2020.

“We shut down our practices . . . and in the weeks later when we reopened, we had dozens of decisions to make. Keeping our patients and staff safe was a priority,” she said.

She then continued on to the importance of building leadership based on culture and values, taking a page from the Academy playbook. Dr. Williams noted several steps to cultivate a positive workplace culture, such as defining the practice’s values and communicating them; modeling those values at all levels, from CEO to administrative staff; hiring staff with those values; and creating opportunities to socialize.

Throughout the pandemic, ophthalmologists have exhibited extraordinary resilience and leadership, said Dr. Williams. From navigating

new ways to see patients safely, to experimenting with telemedicine, this year has certainly made adaptability an asset.

“Now, we’re asking questions on how telehealth might fit into our patient care model,” she said, adding that one of the most important things that happened was the emptying of waiting rooms. This allowed practices to determine how to not only manage patient care, but patient flow going forward. “We can continue to refine the patient experience.”

Further, Dr. Williams described the characteristics of a resilient leader. Among those traits? Being an “excellentist” rather than a perfectionist and the ability to recover from failure. However, the most difficult thing right now she says, is to keep energy high.

“It’s never been more challenging than it is right now to keep our energy high. It’s exhausting to breathe through an N-95 (mask) all day long … and we have to articulate so clearly so our hard of hearing patients can understand us through our muffled masks.

“But our staff and patients need us to be alert and attentive, and energy is one of those things that seeps through an organization,” said Dr. Williams.

“Challenging times are always times of opportunity,” she continued, explaining that when practices closed to flatten the curve, what they were really doing was pressing the “reset” button. “When we began opening up again, we did so by evaluating every single step.”

Place your wager

During the part two of the AAOE Opening Session, Dr. Michael X. Repka provided an update on The Finance and Regulatory Impact on the Ophthalmic Practice, followed by Drs. Robert E. Wiggins, Jr. and Arvind Saini, who discussed The Private Equity Landscape

The pandemic has undoubtedly caused financial

hardship on ophthalmic practices. In his presentation, Dr. Repka covered the various acts passed by the United States Congress to assist American ophthalmologists, as well as pending legislation.

He says that every practice should look into telehealth expansion, even if it’s only for triage: “It will help to have something already in place in case there are new shutdowns,” said Dr. Repka.

Next, Dr. Saini took on private equity from a young ophthalmologist’s (YO) point of view and provided some thoughts for administrators to consider. For example, do mid-career and senior ophthalmologists have a duty to disclose pending private equity (PE) transactions prior to them joining?

Dr. Saini said that in general, for all administrators, practices need to have happy young ophthalmologists because they are main drivers of our practice and the future. “You need to have a strategy of how you will talk about private equity with YOs, if they’re thinking of joining your practice.”

The final presenter was Dr. Wiggins, who offered some PE predictions for 2021. “Private equity in ophthalmology is here to stay,” he said, adding that although there were thoughts the pandemic would cause PE to implode, that wasn’t the case.

Overall, the AAOE Opening Ceremony showed the ophthalmic community’s overall resilience in the face of the numerous challenges of this year. Practices have adapted and will continue to do so … and in unison with this optimistic outlook, we’re hedging our bets, and going “all in” for AAO 2020 Virtual.

We wish we could be welcomed, Las Vegas. We’ll be here virtually, until then …

The Why’s and How’s of Implementing Vision Rehabilitation

In the next 10 years we’re going to see a growing number of visually impaired individuals. This is particularly true for the aging baby boomer population, but low vision also disproportionately affects other vulnerable people such as those with low-income, smokers, diabetics, and people with 1 or more chronic disease. In a knowledge-packed on demand session on the first day of AAO Virtual 2020, four experts outlined the importance of incorporating the needs of low vision patients into your practice. Let’s run through all they had to say in How to Help Your Low Vision Patients: Visual Rehabilitation Primer for Ophthalmologists.

Recognizing the impact of vision loss and the ophthalmologist’s responsibility

Dr. Marc D. Bona introduced the topic by calling to attention the importance of visual impairment treatment in ophthalmology. He sought to increase ophthalmologists’ understanding of vision rehabilitation and of how to approach the issue of vision rehabilitation with patients.

A patient-centered approach is crucial because people have different demands and will tolerate varying degrees of vision loss. Dr. Bona also pointed out that low vision makes someone twice likely to fall, four times likely to experience a hip fracture, and along with that a tendency for activity restriction, increased depression, and social isolation. They may have difficulty

by Elisa DeMartino

driving, working, or even just carrying out simply daily tasks.

“Developing strategies to overcome these barriers is a key part of the vision rehabilitation process,” he stressed, going over what ophthalmologists can do in their process of diagnosing low vision, educating patients, and directing them towards appropriate rehabilitation.

The benefits of a low vision exam

Dr. Donald Calvin Fletcher, with over 30 years of low vision practice in his Wichita office, covered several of the same points but elaborated on testing technique. He is in particular a proponent of the SK Read test, explaining that the jumbled words can identify a pattern of mistakes where patients’ vision compensates. For instance, if the patient has a scotoma to the right, they may see the word “saved” as “save.”

Another main focal point of his presentation was the need for better training with assistive devices. “Too often we think about low vision rehab being, ’oh, give the person a magnifier [and] we solve all the problems for them’ — not the case.” He elaborated by telling a touching story of a patient who had loved to bowl but stopped since becoming visually impaired. His therapist accompanied him to the bowling alley and demonstrated how to use the magnifier. “With that little magnifier,” Dr. Fletcher explained excitedly, “he felt like he could be part of his social network again; he could

push the buttons and be with the guys. And that was significant to him.”

Strategies for helping your patients

Michelle Eileen Buck, OT and CLVT with the Henry Ford Health System, continued on to outline in detail what specific tasks become impossible for low vision patients. She provided tips simple to incorporate, like increasing lighting, minimizing glare with visors or light-colored sunglasses, and maximizing background contrast by, for instance, choosing a colored cutting board during meal prep. She also reviewed vision technology, audio technology, and transportation alternatives while offering a final plug for low vision support groups.

“Interacting with others who are going through the same circumstances,” Dr. Buck concluded, “will give low vision patients the opportunity to ask questions to the group and get new ideas and strategies about how to manage everyday tasks.”

Different models of care in low vision rehabilitation

This session was brought to a close by Dr. Anne Riddering, OT and CLVT with 25 years working in rehabilitation with the Henry Ford Health System’s Center for Vision and Neuro Rehabilitation. She narrated a brief history of vision rehabilitation from the 1920s until now.

After this Dr. Riddering got into some numbers, predicting that the amount of elderly and legally blind people in the United States would double between 2015 and 2030. She pointed to three studies that emphasized the prevalence of multimorbidity in vision impaired people.

After stressing that vision rehabilitation is a prevention tool for falls, lack of independence, problems taking medication, and depression, Dr. Riddering provided some final encouragement.

“Studies examining outcomes have shown that after participating in visual rehabilitation programs, subjects show improvement in the following areas: visual abilities or function, including reading and mobility tasks, self esteem, quality of life, and general health… We don’t save eyes, we save lives!”

Challenging Cases in Neovascular Age-related Macular Degeneration

by Hazlin Hassan

The combined use of anti–vascular endothelial growth factor (antiVEGF) and steroids in subretinal exudation in wet age-related macular degeneration (AMD) can result in improved anatomical outcomes, said Dr. Jay K. Chhablani, vitreo-retina specialist at the University of Pittsburgh Eye Center (USA), during a session on Challenging Cases in Neovascular Age-related Macular Degeneration at the annual meeting of the American Academy of Ophthalmology (AAO 2020 Virtual).

Subretinal hyper reflective material (SHRM) primarily comprises deposits and tissue components which vary in their composition, natural history and response to treatment. SHRM could be neovascular tissue, exudation, fibrin, fibrosis, vitelliform material, hemorrhage or reticular pseudodrusen.

Focusing on subretinal hyperreflective exudation (SHE), which refers to a form of avascular SHRM seen in active type 1, 2 or 3 neovascular tissue, Dr. Chhablani explained that the hyperreflectivity is greater than that of SRF but less than that of subretinal fibrosis, pigment hyperplasia and lipid.

He presented the case of a 69-yearold male, with visual acuity of 20/125, subretinal hemorrhage and some exudation. An OCT revealed the presence of subretinal hyper reflective material. Ranibizumab injection was given, and after a month there was a slight reduction in subretinal fluid, but the SHRM was still there.

The patient was then treated with a second ranibizumab injection, and then received ziv-aflibercept and intravitreal triamcinolone acetonide injection (IVTA). At six months, he was 20/60 with no subretinal fluid or SHRM.

In conclusion, anti-VEGF is a prompt response which can reduce intra-retinal or subretinal fluid, while IVTA inhibits

VEGF, cytokines, and growth factors, and provides local reduction of inflammation.

IVTA is not efficacious as monotherapy, but a combination of steroids and antiVEGF will be able to deal with subretinal hyper reflective exudation which could otherwise become a scar and cause vision loss.

The combination results in an “improved anatomical outcome with favorable effect on subretinal hyper reflective exudation,” said Dr. Chhablani.

Maintaining anti-VEGF injections even when a patient has retinal pigment epithelial tears (RPE) in neovascular AMD, can result in better visual outcomes, said Amani Fawzi, MD, Cyrus Tang and Lee Jampol, professor of ophthalmology, from Northwestern University (USA).

RPE tears are a rare complication in the treatment of patients with exudative AMD and can result in vision loss. RPE tears are known to occur as a natural result in the course of a retinal pigment epithelial detachment (PED) because of underlying choroidal neovascularization (CNV), retinal angiomatous proliferation, or polypoidal choroidal vasculopathy.

Since the use of intravitreal antiVEGF therapies in patients with PED due to exudative AMD, RPE tears have increasingly been reported as a complication after injection.

Risk factors for RPE rips include Type 1 CNV with fibrovascular PED, OCT vertical height (risk is almost 30% in PED>600micron) and halo hyperfluorescence on FA in PED (telltale sign of impending rip).

“So what do you do? The first reaction from most of us is basically to give up and not to do anything,” said Dr. Fawzi. But a study demonstrated that more frequent annual injections correlated with better

visual acuity long-term, she pointed out.

“So you have to persist with these eyes,” she stressed. “The most important thing is persistent injections and you can maintain their vision even after a frustrating initial RPE rip.”

In summary, high-risk retinal PED characteristics need to be recognized, and patients should be counselled about the risk of rips, where 10% are spontaneous and 20% occur with anti-VEGF injections. Lastly, injections should be continued, and one must not give up, especially if fovea is preserved.

The presence of nonexudative neovascular lesions in eyes with geographic atrophy (GA) may have a protective effect against progression of GA, said Eduardo Buchele Rodrigues, MD, Department of Ophthalmology, Saint Louis University (USA).

The prevalence of nonexudative MNV in the fellow eyes of patients with exudative MNV secondary to AMD in analyzed studies ranged between 6.25% and 27%. Globally, in reviewed studies, about 25% of nonexudative macular neovascularization (MNV) lesions became exudative (range 6-20 months), Dr. Rodrigues added.

Eyes with GA and treatment-naive nonexudative MNV have the same risk of exudation as eyes with drusen and treatment-naive nonexudative MNV. But nonexudative MNV may not only slow the progression of GA but could possibly prevent GA altogether, he said.

Recent insights from OCTA studies have shown that large MNV complexes do not disappear with repeated anti-VEGF therapy, which suggests that these neovascular lesions are already mature and do not respond to repeated injections.

“The best management is close followup,” said Dr. Rodrigues.

Glaucoma Symposium Includes Lasers, Surgical Debate and More

by Andrew Sweeney

It would not be an outstanding ophthalmologist conference without a high quality showcase of glaucoma, that most pervasive of eye diseases. The annual meeting of the American Academy of Ophthalmology (AAO 2020 Virtual) did not disappoint, with its many on demand videos, posters and symposia. In the city of showbiz, the AAO really knows how to put on a show.

One of the best examinations of glaucoma was a video series on glaucoma update (SYM26.03Glaucoma Update - Introduction). Instead of being one, longer length video, this symposium was instead split into 11 smaller sections. Beginning with an introduction, Dr. Jo Ann Giaconi of the Stein Eye Institution at the University of California Los Angeles, kicked off the proceedings.

The invited speakers were paired to examine different patient case studies, with each pair taking opposing views and approaches to their case study. The first examined how optical coherence tomography (OCT) and the Humphrey Field Analyzer technique have changed. Specifically, the question of how aggressive treatment of patients using these tools should be, was raised.

Fast progressions and active lifestyles

Dr. Leonard K. Seibold recommended following established guidelines on glaucoma treatment (i.e. using repeated and confirmatory tests before altering treatment). However, Dr. Joanne C. Wen recommended more aggressive treatment. Dr. Wen pointed to macular OTCs being particularly useful and effective in escalating treatment to prevent fast glaucoma progression.

The next section took on a surgical flair, focusing on mild to moderate open angle glaucoma. Dr. Arsham Sheybani

reported on using the Hydrus Microstent on a 73-year-old myopic male with an enlarged blindspot but active lifestyle. He reported that this microstent was superior to phaco alone for unmedicated modified diurnal intraocular pressure reduction.

Dr. Davinder Grover instead focused on an implant free approach to surgery with cataract extraction. While recognizing that there are major variables for each patient, Dr. Grover believes implant free treatment can be particularly beneficial. He said that surgical options should be tailored to the surgeon.

Up next was what medication can be added for a patient with difficult to control IOP. Dr. Angelo Tanna recommended adding a topical carbonic anhydrase inhibitor. He argues this is the best approach — has both a diurnal and nocturnal IOP lowering effect, plus a safety and tolerability profile.

To laser or not to laser?

However, Dr. Nathan Radcliffe prefers selective laser trabeculoplasty (SLT). Citing the alternative of eye drops as causing dry eyes and having a poor

compliance record, Dr. Radcliffe argues SLT is more effective and longer lasting. He reported that disaster deterioration was recorded in one study at 3.8% with SLT and 5.8% with medication.

SLT and topicals were the theme of the next section that investigated a patient who had failed SLT and also failed to adhere to topical application. Dr. Sarah Van Tassel recommended sustained release therapy in this scenario. In particular, she recommended the bimatoprost sustained release intracameral device.

Taking the opposite approach, Dr. Andrew Chan prefers to use surgery. He believes the bimatoprost implant has too limited a duration for effective patient outcomes and causes a decrease in corneal endothelial cell density. Dr. Chan recommends filtering surgeries as an alternative.

Finally, the last section was an update on primary angle closure glaucoma with normal nerves. Led by Dr. Sunita Radhakrishnan, this was an examination of iridotomy, a technique she believes still has considerable application in glaucoma. The session was thereafter ended by Dr. Malik Y. Kahook.

Practical Application of Multimodal Imaging

Meet the Eye Detectives

Deep learning performance is superior to traditional machine learning, and in specific tasks, it exceeds human performance. Over the last decade, there’s been significant progress in applying optical coherence tomography (OCT) and artificial intelligence in macular diseases. There are multiple AI-based fundus imaging systems for diabetic retinopathy screening at various translational stages.

Comparing the use of AI for fundus image with OCT, Dr. Tien Yin Wong explained that it is known that fundus cameras are cheaper and more accessible, with large, diverse datasets and 2D imaging. In contrast, OCT is more expensive, with fewer datasets and 3D imaging. Current AI applications for OCT imaging have been used for single or multiple disease diagnoses, physician support for screening and referral, and detection of specific OCT features such as subtype and fluid. Besides, AI has enhanced OCT’s use in predicting clinical outcomes, for example, conversion to wet AMD, after treatment.

These AI applications in OCT can be applied in different settings such as primary care GP settings, general ophthalmologists, or retinal specialists. What are the challenges of AI and deep learning in OCT? These include a lack of large image datasets from multiple OCT devices and non-standardized imaging and post-processing protocols between devices. Also, there is a lack of similarity in reporting metrics, and some clinical use cases remain unclear. Furthermore, empirical data on cost-effectiveness and impact on ophthalmologists’ practice remains inadequate.

Multimodal imaging: How not to miss retinal drug toxicity (hitting the bull’s eye!)

According to Dr. William Mieler, the key factor to consider in medication-related retinal abnormalities is a thorough

by Olawale Salami

history of medications that the patient is currently using or has used in the past. “It is then imperative to know and recognize usual toxicity patterns from any systemic or topical medication. Multimodal imaging is beneficial in checking for and documenting possible toxicity as well as in monitoring progress,” he said.

Rheumatologists commonly use hydroxychloroquine for the treatment of rheumatoid arthritis and systemic lupus erythematosus. Dr. Mieler described additional features of this drug, stating that: “It has relatively few side effects, other than concerns regarding maculopathy, typically described as Bull’s eye maculopathy on multimodal imaging. This is occasionally seen, though more common pigment mottling and atrophy are noted.

Furthermore, maculopathy is generally seen with high doses of >5mg/kg/day and with prolonged duration of treatment and reports of toxicity have occurred in patients using hydroxychloroquine for more than 5 years, reported Dr. Mieler.

“Multimodal imaging approach aims to screen and detect abnormalities before irreversible visual loss. This involves

fluorescein angiography, OCT, visual fields, and ERG. At baseline, screening recommendations include a complete examination baseline to rule out any coexisting conditions, then annual examinations at 5 years,” shared Dr. Mieler.

Non-retina-friendly drugs: More retinal villains to consider

Several systemic medications are capable of impacting retinal function, even when employed at therapeutic dosages. According to Dr. Mieler, examples of these include pentosan polysulfate, thioridazine, clofazimine, deferoxamine, and several chemotherapeutics.

“While some drugs, for example, vancomycin and ergot alkaloids, can cause vascular damage and occlusion, others such as nicotinic acid, paclitaxel, and diuretics can cause macular edema and induce myopia. Furthermore, other medications can cause crystal deposition in the retina, including tamoxifen, Mmethoxyflurane, and nitrofurantoin,” explained Dr. Mieler.

“Pentosan polysulfate sodium is commonly used to treat nephritis and bladder pain. However, it binds to epithelial cells including retinal pigment epithelial cells, and recent evidence suggests that it causes pigmentary maculopathy, which is more frequently seen in females and is related to the duration of treatment,” added Dr. Mieler.

The Tools to Take on Glaucoma

Exhibitor Showcase

Reporting on the newest products and launches from ophthalmology’s leading companies

by Brooke Herron

Target Underlying Causes

At the Sight Sciences virtual booth, two products are featured prominently: the OMNI® Surgical System and TearCare®.

The OMNI Surgical System is a manually operated device for delivery of small amounts of viscoelastic fluid during ophthalmic surgery; it is also indicated for cutting the trabecular meshwork during trabeculectomy. Attendees can watch a demonstration of the OMNI at the booth.

Next, Dr. Ahmed Fahmy and a patient demonstrate using TearCare, a blinkassisted device that applies heat to the eyelids, whereas a warm compress would normally be used. The device has application in meibomian gland dysfunction (MGD), dry eye, blepharitis, stye or chalazion.

Both devices contribute toward the company’s goal of “transforming ophthalmology and optometry by addressing the underlying causes of the world’s most prevalent eye diseases.”

For more information, visit www. sightsciences.com

A Must Watch: “The iTrace Song”

Okay, friends … if you know us, we like to stand out. And we have to give a round of applause to Tracey Technologies for their featured video. Do yourself a favor, and check out ophthalmology’s newest rock stars, Drs. Paul Singh, David Chang, Jesse McKey, Karolinne Rocha and Arthur Cummings, as they sing “The iTrace Song.”

This clever video literally sings the praises of iTrace: a single piece of ophthalmic diagnostic equipment that performs both wavefront aberrometry and corneal topography with a simple, quick set of scans. Using ray tracing and Placido disk technology, the iTrace performs a complete analysis and generates a literal picture of a patient’s visual function in milliseconds. According to the company, the iTrace and its proprietary ray tracing technology can directly replicate a patient’s vision under any circumstance.

For more information, visit www. traceytechnologies.com

Physician friend and glaucoma foe, New World Medical, is showcasing their arsenal of cutting-edge surgical instruments — all of which target the sight-threatening disease. This includes the Ahmed® Family of Glaucoma Drainage Devices (GDDs), such as the Ahmed® Glaucoma Valve and the new Ahmed ClearPathTM; and the Kahook Dual Blade® (KDB), which is an ophthalmic surgical instrument used for excisional goniotomy.

The Ahmed Glaucoma Valve provides immediate IOP reduction for all types of refractory glaucoma; features a nonobstructive valve system which prevents excessive drainage and chamber collapse; and facilitates easy insertion with a tapered profile. Meanwhile the KDB is designed to aid in trabecular meshwork excisional goniotomy procedures; it can be used in cases of mild, moderate or severe glaucoma, in combination with cataract surgery, or as a standalone procedure.

For more information on these instruments, visit www.newworldmedical. com

Solutions for Surgeons, and Patients

Meanwhile over at the Glaukos booth, attendees are welcomed by company COO Chris Calcaterra in their featured video. In his candid talk, he acknowledges the COVID-19 crisis, then delves into what Glaukos has been doing over the past six months to better serve the ophthalmic community.

“We are committed to serving you and your patients today and in the years to come,” said Mr. Calcaterra. “Whether it be iStent Inject W, our third generation trabecular bypass; or iLink, the only FDA approved treatment option for keratoconus; or our publicly disclosed 13 in-house projects, we will be there for you.”

For more information about Glaukos products, visit www.glaukos.com

125 Years of Innovation

Over at the Oculus Surgical booth, a creative animation introduces the company’s line of single use disposables, including the BIOM® ready (a wide angle viewing system); BIOM optic set (a high-definition wide field front lens and reduction lens), and HD Disposable Lenz for the Zeiss ReSight — all designed to keep ORs safe, with less downtime and no risk of cross contamination.

Other disposable offerings include microscope drapes, the Super View Pivot® (a dual lens system for BIOM), and the Super View HTC

Contact Lens

At the main Oculus booth, the innovation continues as they celebrate their 125th anniversary with a retelling of the company’s history. Featuring historical photos, the video takes attendees on a journey through time with Oculus, as witnesses to growing innovation and key contributions to ophthalmology, like the Pentacam®, the gold standard for anterior segment surgery.

For more information on Oculus Surgical visit www.oculussurgical. com. Visit www.oculus.de for the main Oculus website.

Diagnose with Confidence

Founded in 1975, LKC is known as an industry leader in visual electrophysiology products. One product they’re showcasing at AAO is the RETeval® Portable/handheld ERG device, the first completely portable, handheld, full-field flash ERG (electroretinograms) and VEP (visual evoked potential) testing device for medical professionals. It can be used in both children and adults, and provides valuable information to help clinicians

Maintain Vision with Less Office Visits

If you haven’t already heard, ILUVIEN® is an exciting new treatment for diabetic macular edema (DME) from Alimera Sciences. Speaking in the featured video, company President and CEO Rick Eiswirth shared his personal motto of “Find a way — and not a way out,” and that approach is illustrated with this new treatment.

ILUVIEN (fluocinolone acetonide intravitreal implant; 0.19mg) is indicated for the treatment of DME in patients who have been previously treated with a course of corticosteroids and did not have a clinically significant

One Man Band: All-in-One Devices Take Center Stage

Ziemer North America President David Bragg welcomed attendees to the company’s virtual booth, and shared how the company has used these trying COVID-19 times to innovate and launch new products.

He highlights the Z-Series Femtosecond Laser for cataract and refractive surgery, which offers “the highest repetition rate of any femtosecond laser and overlapping, and precise spots with very low pulse energy.”

rise in IOP. The implant’s CONTINUOUS MICRODOSING™ provides consistent therapy that treats the underlying inflammation that causes DME — which helps prevent retinal damage. Another advantage is that it requires less office visits, while maintaining vision — which is important to both patients and doctors during the pandemic.

“Our vision is to be the place to be in the retina, dedicated to serving you, the retina specialist, and your patients,” said Mr. Eiswirth, affirming Alimera Sciences’ commitment to serving the back of the eye — and only the back of the eye. Visit www.alimerasciences.com for more information.

He also brings up another device: “Now is the time to minimize patient-staff contact by integrating your diagnostics with one single device: the Galilei allin-one topographer, tomographer and biometer,” said Mr. Bragg.

Attendees can also learn more about Ziemer’s new lenticule application, CLEAR (Corneal Lenticule Extraction for Advanced Refractive correction), with the FEMTO LDV Z8. The newly developed proprietary application is intended for the treatment of myopia and astigmatism.

For more information, visit www. ziemergroup.com

make a more effective diagnosis — as well as monitor sight threatening diseases.

LKC is also showcasing the new UTAS Sunburst, which is a visual electrodiagnostic system that can conduct ERG, VEP and EOG (electrooculogram) tests. According to LKC, the new Sunburst features a reduced footprint, as well as upgrades like a pattern-based test monitor, a new UTAS interface, a UBA biomedical amplifier and Windows 10 compatibility. For more information, visit www.lkc.com

Would you like to see your company’s products featured in our daily Exhibitor Showcase? Contact matt@mediamice.com for more information.

Double Vision after Ocular Surgery Should Patients be Worried?

by Olawale Salami

The emergence of double vision (diplopia) after ocular surgery can cause significant concern to both patients and surgeons. In Session: SYM36 (A 2020 Update on 20/20 x 2: Diplopia After Ocular Surgery), available on demand at the annual meeting of the American Academy of Ophthalmology (AAO 2020 Virtual), ophthalmologists explored a variety of facets of postoperative diplopia.

Cataract surgery and double vision: We’ve come a long way

Furthermore, Dr. Klein noted that there seems to be a trend back to the ophthalmologist in administering ophthalmic anesthesia. “There is increased availability and a better understanding of hyaluronidase, and today, topical anesthesia has become the most commonly used anesthesia for cataract surgery,” said Dr. Klein.

Diplopia following retinal surgery: Watch the buckle

or surgery. Horizontal deviations are more common and suspect superior oblique muscle entrapment if the patient presents with limited downgaze.

“Removing scleral buckling may increase the risk of retinal detachment and is not recommended as the treatment of choice,” Dr. Velez advised.

Diplopia after IOL insertion

According to Dr. Marlo Galli, IOL and laser surgery-induced monovision may also induce postoperative diplopia. The patients most at risk are those with preexisting binocular issues, postoperative anisometropia of > 1.5, and high myopia.

“Therefore, good history and clinical examination are important, to exclude risk factors such as childhood strabismus, glasses before the age of 5 years, patching, or eye exercises,” said Dr. Galli.

Diplopia following glaucoma surgery: Watch out for those implants

How often does diplopia occur after glaucoma surgery? According to Dr. Hilda Capo: “We see quite a wide range, from 1.4% to 23% of cases and the causative mechanism include anesthetic myotoxicity from a nerve block and mechanical factors related to the implant.”

Dr. Sherry Klein provided a narrative of the evolution of post-cataract surgery treatment in the United States. “I remember in early 2000 when there was a shortage of hyaluronidase, resulting in an increase in myogenic toxicity, mostly to the inferior rectus muscle and anesthesia-related palsies,” she noted.

However, things are quite different today. “Today, I’m happy to report that I rarely get postoperative cataract patients referred to me with diplopia,” shared Dr. Klein. “This could be because there has been greater training, standardization, and validation to ensure adequate nerve block administration by the anesthesiologist,” she added.

According to Dr. Federico Velez, retinal surgeon, and professor of ophthalmology at Duke University, transient diplopia is quite common in the immediate postoperative period, occurring in up to half of patients and is resolved within 6 months. On possible causes, Dr. Velez said: “The underlying mechanisms include direct muscle trauma, myotoxicity from retrobulbar anesthesia and mal repositioning of a detached muscle.”

“Besides, in other cases, it may be related to postoperative adhesions and a scleral buckle,” said Dr. Velez.

According to Dr. Velez, the clinical patterns are quite variable. These include reverse restriction, muscle tightening or slippage, and superior oblique entrapment. Treatment includes the use of prisms, chemo-denervation,

“It is more common in patients following insertion of glaucoma drainage devices (GDD), as compared to trabeculectomy,” said Dr. Capo.

On the surgical treatment of diplopia following glaucoma surgery, Dr. Capo explained that strabismus treatment after GDD implantation is difficult because of scarring GDD plates and surrounding capsule, limited fusion potential, and multiple underlying pathophysiological mechanisms. “Surgical treatment depends on the cause, and it might require the removal or repositioning of GDD to a different quadrant, resection of affected, and antagonist muscle in the affected eye,” said Dr. Capo.

“Overall, we see that surgical success rates are lower than in primary strabismus surgery,” she added.

“Nothing can be more disheartening for the ophthalmologist to go through successful cataract surgery only to discover that your patient is miserable with postoperative diplopia.”

—Dr. Shelly Klein

“Understanding the anatomy is important because the magnitude of the extraocular muscle misalignment following scleral buckling surgery is related to the risk of diplopia.”

—Dr. Federico Velez

Improving Feedback Improves Medical Practices

by Sam McCommon

The takeaway? Employees don’t just need more feedback — they need more clear, direct, specific feedback.

Giving good feedback

Feedback needs to be carefully considered by a manager. And while managers don’t need to fall all over themselves praising employees, commending specific behavior can help reinforce that behavior and encourage other employees to do it too.

Imagine, for example, a patient in a waiting room is clearly frustrated or confused by a form. If the receptionist notices and walks over to help, that’s clearly positive behavior (pre-COVID, at least). A manager should notice and praise this behavior, even if it’s just a brief thanks. The employee will certainly appreciate it.

One of AAO 2020 Virtual’s major focuses is on the business side of ophthalmology — perhaps an under discussed topic, often drowned out by the, well, ophthalmology side. But running a practice takes plenty of skill, and is an entirely different skill set than performing eye surgery. No matter how skilled an eye surgeon may be, the skills do not translate to business management.

So, on that note, day one featured a presentation on management practices by Maureen Waddle of BSM Consulting, a healthcare business management company. She provided some valuable, actionable tips for healthcare managers and those who manage the managers — as well as eyebrow-raising insights.

If you’ve noticed your managers are feeling burdened, or if you yourself feel burdened by managing a team, take heed of the following bits of wisdom.

Always the firefighter, never the fire

Mrs. Waddle made an apt analogy comparing managers to firefighters. And, indeed, if you asked managers how they felt, many would say they felt like they were always putting out fires.

But let us recall that actually putting out fires is not what firefighters do with most of their time. Instead, they both train to put out fires and proactively prevent fires from happening in the first place.

One valuable way to prevent ‘fires’ in the workplace is to improve the quality of feedback given to staff. Since a business cannot function without its staff, their proper management is tantamount to success.

Surprising statistics

Feedback — both positive and negative — is crucial to helping employees do their job right. And the statistics provided by employees surveyed shows that most companies don’t get it right. Specifically:

• 55% of employees surveyed said positive feedback isn’t specific enough.

• 65% of employees surveyed indicated negative feedback was too general to help them improve.

• 79% of employees surveyed stated that they didn’t have a clear understanding of their employer’s opinion of their performance.

If negative behavior needs to be corrected — for example, being late to work — a manager needs to directly tell the employee how the problem impacts the team and the practice in general. It’s important to not confuse the person with the problem — the problem is what’s being addressed, not the person. By limiting the criticism to a specific problem behavior, the employee is less likely to get defensive than if they feel their character is being attacked.

Doctors will need to give feedback to their managers as well to help them lead as effectively as possible. When providing criticism, for example, be sure to add a next step so they know what to do to improve. This helps the employee navitage uncertain waters — rather than simply feeling condemned, they’ll know how to correct what’s wrong.

Making the right decisions

There’s far more to discuss about leadership and managerial skills, but simply improving feedback can be a valuable improvement. Making sure your staff feel well trained and empowered can help them make the best decisions possible. And that leads to better results for your practice, and thus your patients. Everyone wins. That’s what we all want, isn’t it?

Rethink Your Office Layout with Lean Healthcare Design

by Elisa DeMartino

The scope of eye care doesn’t stop at interior design! Dr. Samuel C. Spalding and invited speakers made great effort to demonstrate this with their examples of pod layouts and equipment reorganization in this AAO Virtual 2020 session, Lean Healthcare Design for Ophthalmology. I was almost convinced to incorporate this clustered layout — and I don’t even have my own clinic!

Trimming the fat

When you see the word lean perhaps you think of a lean cut of meat. That’s precisely in line with what healthcare professionals are getting at when they discuss “lean” practices. As described by Aneesh Suneja, MBA and and Lean Coach for Austin Retina Associates and RVS of Central NY, lean practices identify wastes during the work day with a goal in mind to reengineer or eliminate those wastes. Using value stream mapping and lean analysis a clinic can identify that, for instance, only 40 minutes of a patient’s 90 minute visit is spent in actual face-to-face time with their doctor and eventually cut out wasted time to accommodate more patients.

Patients aren’t the only factor here: Beth Fritz, of AIA and Dwyer International with 13 years in healthcare architecture, elaborated that employees can also lose valuable time due to waste walk and bottlenecks in the office. She suggested ophthalmology clinics make a list of spaces they need and which should be next to each other taking into

consideration movement of staff and patients, commonly accessed things like printers and bathrooms, and stakeholders in charge of decision-making.

Dolphins swim in pods… why not offices?

Ms. Fritz introduced the concept of podbased work spaces. In fact, throughout the session speakers swore by this practice and described how it worked for each of their clinics. The common determination was that clinics became much more efficient when organized into clusters. Dr. Jose Agustin Martinez suggested clustering 3 exam rooms, 3 screening rooms, and an OCT room together instead of placing, as has been done traditionally, all exam rooms together and so on.

Dr. Martinez cited that using pedometers staff and technicians in his office had been walking 10,000 steps per day, totaling an hour and 20 minutes daily of just walking around. After implementing the pod layout staff now walked 3,000 steps per day.

Dr. Stephanie Collins Mangham, COA, MBA, OCSR, shared that the pod system improved line of sight, communication, accountability, and team mentality while reducing bottlenecks and waste walk.

Minor modifications can go a long way

“You don’t have to actually rip down a bunch of walls or put a bunch up

if you can look at creating pods and adjusting things.” Dr. Mangham assured this during her presentation. Her office started with small changes: adding a small fridge to each area for medicines, doing the same with individual supply stations, and installing separate upload stations for OCT and FA uploads.

Dr. Jamin S. Brown was in agreement with her, stating that “redesign can start as small as a drawer.” It certainly doesn’t require a wrecking ball to standardize drawer organization so that in each supply drawer cotton swabs are on the bottom right! Yet Dr. Brown acknowledges that eventually, after trying every organizational trick in the book, it can still sometimes come down to not having enough space.

Getting started with lean design

Dr. Spalding nudged the audience to ask the important questions. Why is your current space unsatisfactory? Can it be fixed with scheduling? Do you need more (or less, perhaps) square footage? Do you renovate the space or build anew? He reminded that focus should be given to patient experience first but also to provide space for required tasks, facilitate staff communication, and optimize patient and staff traffic patterns.

The speakers closed with a Q&A and some key takeaways:

“A lot of the trials you come up with will fail,” Dr. Brown offered. “But you will learn something with every success and every failure”

Beth Fritz underlined that, in order to adequately implement lean design, “it’s really important to establish who those stakeholders are. Who are the decisionmakers? It’s that group that is going to ultimately decide.”

In an encouraging voice, Dr. Suneja summarized that “most buildings seem to be designed to be used differently than they are currently being used. More of the answer is the mindset of the physicians and the staff working out of their own silos and having a conversation around patient experience and how to utilize the current space in a more efficient way.”

Technology and the Elderly Friends at Last?

by Sam McCommon

sense: It saves everyone’s time, it maintains social distancing practices, and it’s simply more convenient.

Day one of AAO 2020 Virtual featured a valuable symposium that explored the technological landscape of low vision rehabilitation. The two presenters mainly discussed the role of technology in assisting elderly people with failing vision — and there are some very promising developments taking place.

While there have long been tools to manage low vision patients, there have always been plenty of barriers to success as well. And although these tools do not cure or rehabilitate the eye itself, they can drastically improve a patient’s quality of life through their successful use.

Video magnification: The way forward

Dr. David Calvin Fletcher explored the world of video magnification and presented a case study that summed up his points rather succinctly. It may surprise some to learn that video magnification has been around since the 1960’s. A doctor named Sam Genensky invented it partly to help himself, and it’s been around ever since, though in varying forms.

Dr. Fletcher astutely pointed out that the value of a technology can often be indicated by its longevity — and in the ophthalmic world, decades of use is a very long time indeed. Even now, video magnification doesn’t appear to be going the way of the dodo anytime soon. Rather, when compared to optical magnification, electronic magnification is better in just about every way.

He introduced a case study with an elderly lady whose vision was fading, but whose mind was still sharp. She loved to read, but found reading continuous text like that in magazines or books very frustrating with her optical magnifier. So, Dr. Fletcher ordered her a digital

magnifier with a 12” screen — and she loved it.

The trend towards digital magnifiers is accelerating because the technology is getting cheaper and better. Dr. Fletcher’s own recommendations of digital magnifiers doubled just between 2013 and 2018. However, he notes that patients need to be trained to use it — because, let’s face it, not every grandparent is a technology wizard.

The ever-increasing role of telemedicine

Dr. Ava K. Bittner of UCLA’s Stein Eye Institute described the positive impact telemedicine has had and will continue to have for low-vision patients. The year 2020 has been the year telemedicine exploded onto the scene — so at least something good came out of this godforsaken year.

With new patients, lots of time is spent in the doctor’s office simply gathering information. The information-gathering, initial conversation phase of the doctor’s visit can be moved to telemedicine, suggested Dr. Bittner. It makes perfect

It’s also valuable for maintaining followup visits. Many low-vision patients — as many as 50%, in fact — miss their yearly checkup according to Dr. Bittner’s estimation. This could be due to a host of reasons, including difficulty driving, other medical conditions, distance, and more. Telemedicine makes all those points moot, and is generally very well received by patients and doctors alike.

Like Dr. Fletcher, Dr. Bittner is a proponent of digital reading aides. She also agrees that patients need training to use them — and has numbers to back it up. Specifically, for patients with visual acuity worse than 20/63, 1-3 training sessions with their new tool dramatically improved their vision ability. She noted that users may make many more mistakes than doctors might assume, so training is necessary. And it may even be valuable to contact local volunteer organizations like the Lions’ Club to help set up the equipment for elderly users.

We are the robots

Finally, Dr. Fletcher introduced the concept of socially assistive robots to help the elderly with daily tasks like exercise. Interestingly, there is a clear preference among the elderly for a physical robot rather than simply a robot on a screen. So, maybe soon the elderly will have new, robotic live-in companions. Who knew the future would be so wild?

DURYSTA Bimatoprost Implant

The First SustainedRelease Implant for Glaucoma

by Hazlin Hassan

endothelial cell dystrophy, prior corneal transplantation or endothelial cell transplants, absent or ruptured posterior lens capsule, hypersensitivity to bimatoprost or to any of the other components of the implant.

The presence of DURYSTA implants has been associated with corneal adverse reactions and increased risk of corneal endothelial cell loss. Administration of DURYSTA should be limited to a single implant per eye without retreatment.

Caution should be used when prescribing DURYSTA in patients with limited corneal endothelial cell reserve.

DURYSTA should be used with caution in patients with narrow iridocorneal angles or anatomical obstruction that may prohibit settling in the inferior angle.

Macular edema, including cystoid macular edema, has been reported during treatment with ophthalmic bimatoprost, including DURYSTA intracameral implant.

Glaucoma is the leading cause of blindness and visual impairment in the United States.

One of the challenges in treating open-angle glaucoma (OAG) and ocular hypertension (OHT) is that patients sometimes forget to use their medicated eye drops which are important in managing intraocular pressure (IOP). Some may even forgo them due to side effects such as dry eye.

The DURYSTA™ (Allergan, Dublin, Ireland) bimatoprost implant, is the first sustained-release implant for glaucoma and allows patients to manage their eye pressure without having to use topical eye drops.

It continuously delivers bimatoprost, a prostaglandin analog, over several months, helping to reduce and maintain healthy eye pressure levels.

“There is consistent IOP control for several months and up to 33% IOP reduction,” said Jason Bacharach MD, medical director and founding partner of North Bay Eye Associates (USA), during his presentation on the safety and effectiveness of DURYSTA at the annual meeting of the American Academy of Ophthalmology (AAO 2020 Virtual) on Friday (November 13).

The implant’s extended IOP control over several months has been proven in Phase 3 studies. DURYSTA was evaluated in two multicenter, randomized, parallelgroup, controlled, 20-month (including eight-month extended follow-up) studies compared to twice-daily topical timolol 0.5% drops in patients with OAG or OHT.

DURYSTA demonstrated a mean IOP reduction of approximately 5 to 8 mmHg over 15 weeks in patients with a mean baseline IOP of 24.3 mmHg, said Dr Bacharach.

The preservative-free medication is housed within a tiny rod-shaped cartridge. The implant comes pre-loaded with 10 mcg of bimatoprost in a sterile single-use applicator that is used to inject the implant directly into the eye.

“This year at AAO 2020 Virtual, we’re proud to present new data for our IOPlowering treatment DURYSTA, which delivers a much-needed option for glaucoma patients challenged by topical drops,” said Michael Robinson, MD, vice president, global therapeutic area head, ophthalmology, AbbVie, in a statement.

However, not everyone is an ideal candidate. It is contraindicated in patients with active or suspected ocular or periocular infections, corneal

DURYSTA should be used with caution in aphakic patients, in pseudophakic patients with a torn posterior lens capsule, or in patients with known risk factors for macular edema.

Prostaglandin analogs, including DURYSTA, have been reported to cause intraocular inflammation.

DURYSTA should be used with caution in patients with active intraocular inflammation because the inflammation may be exacerbated. Intraocular surgical procedures and injections have been associated with endophthalmitis. Proper aseptic technique must always be used with administering DURYSTA, and patients should be monitored following the administration.

In controlled studies, the most common ocular adverse reaction reported by 27% of patients was conjunctival hyperemia.

Other common adverse reactions reported in 5%-10% of patients were foreign body sensation, eye pain, photophobia, conjunctival hemorrhage, dry eye, eye irritation, intraocular pressure increased, corneal endothelial cell loss, vision blurred, iritis, and headache.

The Professionalism Tree

A Solid Metaphor for a Trying Time

So it seemed fitting in this trying year for AAO 2020 Virtual to host a symposium on Professionalism in Ophthalmology — which extensively dealt with the hard parts of being and remaining professional. After all, if true professionalism were easy, would it be so respected or sought after?

The panel first explores a definition of professionalism, and then explores its components and how to best make use of them. The goal? To be not only the best physician but also the best person you can be. Such a goal is lofty indeed, but it’s the lofty goals that are the most worthwhile.

Defining professionalism

Before the exploration, it’s necessary to have a working definition of professionalism. Dr. George Brian Bartley led us through this aspect, and summed it up rather succinctly.

In short, professionalism is the application of virtue to practice.

As he noted, the doctor-patient relationship is not equivalent to a standard contract between a service provider and a customer. Rather, the relationship relies upon a promise from the doctor to do their utmost to help a vulnerable person. It takes a unique and strong set of morals to gracefully uphold such an agreement, and for the doctor to work for the patient’s own best interests instead of his or her own.

The professionalism tree

A strong metaphor took root (no pun intended) in Dr. Hans Grossniklaus’s concept of a “professionalism tree”, with an individual being the trunk and their parents and background being the soil from which they grew.

The branches were divided into separate components of professionalism that were each covered in greater detail in subsequent talks. The components

by Sam McCommon

represented are briefly detailed in the sections below.

Inspiration

Inspiration is your “true north” and calling; it’s what made you want to be a physician. Dr. Donny Suh pointed out that while a person can lose sight of their inspiration, which can lead to significant stress. If you lose the “why” of what you do, the stress it generates can lead to professional death — burnout.

Dr. Suh noted that inspiration can be activated, captured, and manipulated. It must be actively sought out in order to consistently remind yourself of your direction. He cited his love of helping individuals improve their lives as his motivation — a laudable goal.

Counsel

Counsel is the advice you seek from others in your life, whether in your inner circle or from those in your profession. Dr. Jennifer Lim counsels that seeking counsel can be extremely valuable: It helps keep you grounded and forwardthinking.

She cited a study by the O.C. Tanner Institute which concluded 72% of those who had received awards for their work sought counsel from people outside their inner circle (i.e. their friends or family).

Additionally, a study showed that seeking counsel led to a near 20% drop in stress and 17% in burnout in the group who sought counsel, as opposed to an increase in both in those who did not seek counsel.

Work/life balance

Dr. Julie Haller discussed the alarming impact COVID-19 has had on work-life balance. She noted specifically it has dramatically impacted women, who are leaving healthcare companies in droves due to burnout.

For physicians, the work-life dichotomy is a false dichotomy because work is life;

you can’t be a physician and not have that be a significant part of your life. And when all else fails, use your money to save time on menial tasks to avoid burnout.

Benchmarks/Milestones

Milestones are ways that you measure your own progress. Dr. Mary Elizabeth Hartnett suggested that over the course of a career, milestones transition from seeking external validation to internal recognition of one’s own success.

Stepping back and recognizing your own progress over time allows you to compare yourself to your former self, and also gives you a way to plan for the future.

Resilience

Dr. Alison H. Skalet argues that resilience can be a learned skill. Most notably, she suggests that operating from a position of personal strength or skill allows a person to be much more resilient than from an area in which one is less competent.

True skill allows a person to reach a state of ‘flow’. Those who have experienced flow — being really in the zone at something they’re skilled at — leads to a strong sense of satisfaction. When one is satisfied, one is resilient as well.

She also pointed out that maintaining strong connections with both friends, family, and community is a critical part of resilience — since those without a support network tend to crumble much more quickly. Humans are, by definition, social creatures after all.