Learn when to treat or refer an acute neuroophthalmic case

Acute Neuro-Ophthalmic Problems

Should I treat? Should I refer? by Olawale Salami

In a busy comprehensive ophthalmology practice, a patient with a possible neuro-ophthalmic problem such as sudden vision loss or eye pain diplopia must be evaluated thoroughly and managed expeditiously. Immediate referral to a neuro-ophthalmologist may be appropriate, but practical issues of access and distance may preclude this solution. The comprehensive ophthalmologist needs to recognize these neuro-ophthalmic problems and arrange for timely and appropriate diagnostic studies and management until the referral is possible.

Sudden vision loss with pain: Expect the unexpected

“Always consider optic neuritis in a young white female who presents with a sudden onset of painful vision loss,” advised Dr. Tariq Bhatti of the Mayo Clinic (USA), during his presentation at AAO 2020 Virtual in a session where application approaches to neuroophthalmic cases were discussed.

The most common cause of acute vision loss in a young person is acute demyelinating optic neuritis due to optic neuropathy. It is characterized by rapid, unilateral, painful vision loss, decreased color vision, rapid visual field defect, and optic edema in about a third of cases.

According to Dr. Tariq Bhatti, our understanding of optic neuritis comes from the optic neuritis treatment trial, a randomized study that evaluated the efficacy of steroid treatment in acute optic neuritis and its relationship with multiple sclerosis. The trial enrolled 457 patients who were randomized to receive either oral prednisolone, IV solumedrol + oral prednisolone or oral placebo. Most of the enrolled participants were young white females. better. Besides, patients who received solumedrol recovered faster, compared to other groups. The authors also found an association between optic neuritis and multiple sclerosis based on brain MRI images,” said Dr. Bhatti.

However, when is optic neuritis NOT optic neuritis? According to Dr. Bhatti, here is published evidence showing that up to 60% of diagnosed cases were not optic neuritis, and were simply headaches and functional vision loss. The reasons for misdiagnosis were broad. There was over-reliance on a history of pain with eye movements, a family history of multiple sclerosis, failure to consider an alternative diagnosis, error in interpreting physical exam findings, and misinterpretation of the MRI.

Physicians should consider an alternative diagnosis: bilateral simultaneous vision loss, progressive, irreversible vision loss, painless vision loss, non-white race, retinal pathology, and history of constitutional symptoms.

Sudden vision loss in an elderly patient: Be expeditious!

“When elderly patients present with a sudden loss of vision, always think of a stroke, and if you examine and find evidence of a central or branch retinal artery occlusion, immediate referral to a stroke centre or emergency department is required,” said Dr. Sophia Chung, Clinical Professor of Ophthalmology and Visual Sciences, Clinical Professor of Neurology, University of Iowa Carver College of Medicine (USA).

Both the American Heart Association (AHA) and American Stroke Association (ASA) include retinal ischemia in their case definitions of stroke, and these patients are at an increased risk of stroke. Several studies have shown that up to a quarter of patients with retinal ischemia have MRIs that show silent infarctions, and up to 65% have multiple lesions.

“When fundus examination shows features of anterior ischemic optic neuropathy, this is an emergency as the risk of contralateral vision loss is up to 75%. Here it’s important to institute high dose corticosteroids treatment before referral,” said Dr. Chung.

According to Dr. Chung’s key message during her presentation, all patients with acute retinal ischemia, pituitary apoplexy, and homonymous hemianopia should be referred to the nearest stroke center. “Patients with arteritic anterior ischemic optic neuropathy should be treated with high dose steroids, while patients with non-arteritic ischemic optic neuropathy should be managed conservatively,” she said.

Artificial Eyes in 2020 and Beyond

(Including Telehealth)

by Andrew Sweeney

Artificial eyes are something we are all familiar with and they have been present in the popular imagination for some time. Perhaps best associated with pirates or roguish characters (which would be fitting for somewhere like Las Vegas), artificial eye development has advanced light years of late. The future is bright for this area of ophthalmology, and perhaps surprisingly, this could be partially due to the coronavirus pandemic.

That was one of the subjects discussed during The Artificial Eye: 2020 and the Dawn of Innovation, a symposium organized on day two of the annual meeting of the American Academy of Ophthalmology (AAO 2020 Virtual). The forty-five minute long session offered an extensive discussion on artificial eyes in 2020. Split into three distinct sections, the symposium also included the Parker Heath Lecture which highlighted incubation and entrepreneurial initiatives to guide research in artificial eye development.

Seeing into the future with artificial eyes

The first section was Corneal Cell Therapy with Magnetic Nanoparticle Delivery by Dr. Jeffrey Goldberg. Pointing to significant results in human trials, Dr. Goldberg stated that both epithelial and endothelial cell transplants hold ‘great promise for vision replacement across many diseases.’ Pointing out that corneal transplants have consistently risen in demand year on year in the United States, Dr. Goldberg also reported on the potential of magnetic cell delivery technology. This acts as a regenerative platform where human corneal endothelial cells are expanding in culture. Reportedly, a single donor cornea can yield enough cells for 100s of patients, thus alleviating considerable donor shortages. The first human clinical trial was carried out successfully and a phase 1b trial in the United States is underway, lasting 18 months.

Next up was Dr. Mark Humayun who presented Bioelectronic Artificial Sight, an in-depth look at artificial sight technologies and implants. Dr. Humayun reported on the considerable developments in prostheses for sight, pointing to the Argus II (an epiretinal prosthesis) and the Pixium (a subretinal prosthesis) as showing particular promise. He also reported that a number of both software and hardware developments are underway to improve prosthesis technology.

Self-reported use of the Argus II, according to Dr. Humayun, has been generally positive, with patients even being able to participate in activities like archery and bowling. Base visual acuity with the Argus II implant was reported at 20/1200 to 20/480, however this

remains under review. Baseline visual acuity for the Pixium was reported at 20/400.

The future’s bright, the future’s telehealth

The last segment was the Parker Heath Lecture: The Accelerated Move to Digital Healthcare, given by Dr. Tom Giannulli. The session covered the transformation of the healthcare system via digitization, accelerated by the coronavirus pandemic and telehealth uptake. Dr. Giannulli reported that telehealth usage had increased by up to 45% in the last six months.

This will impact the development of artificial eye and prosthesis devices as wearable monitoring and artificial intelligence technology will increase in both quantity and quality. Dr. Giannulli reported that there is a potential $250 billion market in this area. He also states that 20% of all emergency visits could also be avoided thanks to digitization.

These three segments were subsequently followed by a short discussion segment. The main presenters involved in the symposium discussed bionic eye development, as well as infection rates and adverse reactions involving corneal implants. Stimulation applied to the retina, as well as to the visual cortex, was also raised, bringing an interesting end to the symposium.

AAO 2020 Exhibitor Showcase

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

by Brooke Herron

Optimized IOLs

Founded in 1989, Aaren Scientific aims to develop the most scientifically advanced intraocular lenses (IOLs) and surgical products for the ophthalmic industry.

Positioned as a global distributor of IOLs, Aaren Scientific has remained committed to the core directive of

Sustained Release

Specialty Pharmaceuticals

“EyePoint Pharmaceuticals is a specialty pharmaceutical [company] dedicated to preventing blindness,” said President and CEO Nancy

Lurker in the company’s opening video. “We’re one of the leading drug delivery companies in ophthalmology, transitioning from a R&D company to a fully integrated, specialty pharmaceutical company.”

EyePoint is commercializing its two products in the United

States: DEXYCU® (dexamethasone intraocular suspension) 9% and delivering state-of-the-art products with the highest visual acuity. These include IOLS such as Aqua-Sense®, BioVue® and Adaptiv™ Aspheric IOLs.

Manufactured using Aaren’s proprietary P.U.R.E. System (Precision UnResolvedmaterials Extraction), Aqua-Sense IOLs have enduring optical clarity and enhanced biocompatibility.

P.U.R.E. removes materials and extraneous processing materials found in hydrophilic lenses that are not fully polymerized.

Another proprietary feature is heparin surface modification (HSM). All BioVue IOLs feature HSM, designed with the ultimate biocompatibility available in IOLs today. Meanwhile, the company’s Adaptiv Aspheric IOLs are designed to compensate for aberrations of the eye, even in cases of clinically occurring IOL misalignment or tilt, and give the patient better intermediate vision after cataract surgery. Visit https://aareninc.com for

more information. YUTIQ® (fluocinolone acetonide intravitreal implant) 0.18mg.

“DEXYCU is the first and only FDA approved sustained release steroid (dexamethasone) for the prevention of postoperative inflammation,” said Lurker, adding that it will be commercialized for cataract surgery.

YUTIQ was approved in Q4 2018. It’s indicated for the treatment of chronic noninfectious uveitis affecting the posterior segment; YUTIQ has been proven to reduce uveitis recurrence. For more details, visit https:/ eyepointpharma.com.

A Truly Virtual Experience

Another can’t miss stop at the AAO 2020 Virtual exhibition is Santen’s virtual booth.

Santen is a global specialized company dedicated exclusively to ophthalmology and the research, development, and commercialization of pharmaceutical, surgical and OTC eye care products. Headquartered in Osaka, Japan, Santen provides innovative solutions in retina, glaucoma, uveitis, dry eye, ocular allergy and infection to patients around the world.

After registering, wander around the company’s virtual booth to learn more about its products or chat with Santen representatives. For more information, visit www. SantenUSA. com.

Growth, During the Pandemic

President and CEO Shervin Korangy welcomes attendees in the featured video at the BVI booth at AAO Virtual 2020: “You may have noticed that in the past months we’ve been busy, bringing more innovation to market. We are committed to working with world-class surgeons and making a difference in ophthalmology,” he began, noting that while some companies have pulled back during COVID-19, BVI has made progress.

“This summer, we launched our first IOL into the U.S. market: iPure®, which is a preloaded aspheric monofocal IOL. iPure’s unique three zone aspheric optic has been well-received by surgeons across the U.S. as they seek to streamline cataract surgery,” shared Korangy.

“I hope you have a successful conference and enjoy the products we’ve chosen to feature from our broad portfolio,” he concluded. BVI is also highlighting its Malosa® Single-use Instruments for cataract and refractive surgery and the company’s custom Procedure Packs to improve OR efficiency.

Remote Monitoring with Confidence

With a focus on providing patient-centric ophthalmic diagnostic services, Notal Vision’s ForeseeHome is a home-based monitoring program for intermediate dry age-related macular degeneration (AMD) patients to detect the conversion to wet AMD earlier. This helps extend monitoring from the clinic into the home to further support patient care. These types of devices are even more important now during the COVID-19 pandemic, when less elderly patients are less inclined to make regular office visits.

Clinical data has shown that the ForeseeHome has clear benefits for patients. For example, using the ForeseeHome, 94% of patients who progressed to wet AMD retained functional vision (≥20/40); versus only 62% of patients using standard detection methods alone. Further, adding ForeseeHome reduced vision loss at wet AMD diagnosis by 6 letters compared with standard care alone.

They also found that office visits triggered by using ForeseeHome as part of a home monitoring plan were 16 times more likely to catch new cases of wet AMD, compared with routine scheduled office visits. For more information about ForeseeHome, visit www.foreseehome.com.

DMEK Wet Labs Available

Seattle, Washington-based CorneaGen is a mission driven company: “Even in the midst of a global pandemic, we at CorneaGen are committed, more than ever, to fulfilling our mission to eliminate corneal blindness by 2040,” said J.D. Osbourne, vice president of surgical products and services at CorneaGen.

Based in Seattle, CorneaGen supports corneal surgeons and their patients with the latest products, delivery of the highest-quality tissue, surgeon education, and advocacy for patient access and reimbursement policies.

The company offers products including

All about MIGS

The Hydrus® Microstent from Ivantis is a revolutionary canal-based minimally invasive glaucoma surgery (MIGS) device for adult patients with mild to moderate open-angle glaucoma undergoing cataract surgery. The device is 8mm in length, and it is contoured to the curvature of the Schelmm’s canal; it also features a rounded distal tip, for easy entry into the Schemm’s canal. Further, its open scaffold design provides pathways for aqueous outflow; while its aqueous inlet bypasses the trabecular meshwork to restore flow from the anterior chamber into Schlemm’s canal. The featured video continues with more product details, including its straightforward delivery system, with a tracking wheel and adjustable cannula. The company shares that the Hydrus Microstent is also the first and only MIGS device with clinical results from a pivotal trial reported at four years (HORIZON). For more information about Ivantis and the Hydrus Microstent, visit www.ivantisinc.com. the Geuder Pre-Loaded Glass Cannula for DMEK; Intacs® for Keratoconus; Nano-Thin™ Tissue for DSEK; VisionGraft®; and tissue storage media with antifungal Ampho B.

With a focus on innovation and education, CorneaGen has also developed a safe, DMEK wet lab opportunity for those who would like to transition over to DMEK.

“We want you to know that we continue to be vigilant during the pandemic to ensure we are providing safe donor tissue,” said Osbourne, adding that virtual consultations are now available for all products and services. For more, visit https://

corneagen.com.

Reduce the Medication Burden in Glaucoma

At the Iridex AAO 2020 Virtual booth, the MicroPulse P3® Delivery Device, a versatile and non-incisional glaucoma treatment with MicroPulse® transscleral laser therapy.

New York-based ophthalmologist Dr. Nathan Radcliffe recommends MicroPulse laser therapy to a variety of patient types within his practice. “This is a treatment option for patients who are unhappy or uncomfortable on their current glaucoma medications, and who are also uncomfortable with the idea of traditional glaucoma surgery, which may have higher risks,” he explained in the featured video.

Next, Dr. Oluwatosin Smith shared her experience: “I’ve done many MicroPulse laser [treatments] on patients and patient outcomes have been really good; intraocular pressure has been reduced and the laser has been effective in achieving the goals that I’ve set — like reducing the number of medications that they’re on.”

For more information, visit www.iridex. com.

Mitigating Cyber Security Threats in

Healthcare by Elisa DeMartino

Cybersecurity. It’s no doubt a word you’ve come across in the news or among colleagues and cohorts countless times in the last several years. In 2020 this term has become a focal point of attention, for as technological innovation grows so do opportunities for data theft. This is especially true with our growing reliance on technology and remote capacities during the COVID-19 pandemic.

Under AAO 2020 Virtual’s On Demand selection Jeffrey Daigrepont, Senior Vice President at the Coker Group, spent the better part of an hour programming viewers to account for cybersecurity threats in the medical industry in his presentation titled Cybersecurity Update: New Threats for 2020 and Beyond and Internet of Things Risk. We can’t be more appreciative of this fact-filled briefing of a topic that is sometimes only skimmed by decision-makers.

Types of threats

Mr. Daigrepont familiarized us by outlining the ways in which a hacker might obtain private information. Some of the methods he went over include:

Ransomware: Computer malware that installs covertly onto a victim’s computer and demands a ransom payment for information stolen.

Social engineering: Finding personal information about an employee on a personal level and using it to trick them into doing something.

Baiting: Presenting false incentives to the target to tempt them into taking a certain action that makes them susceptible.

Phishing: Sending emails from addresses that look legitimate, linking to fraudulent websites or dangerous downloads. He provided an interesting explanation of the reasoning behind such methods. “Criminals by nature are very lazy. They’re desperate people.” He elaborated that “they’re not very interested in working very hard, otherwise they’d have real jobs… And so they basically seek out soft targets, and they find that doctor’s offices are oftentimes very, very soft targets.”

What’s at risk?

By utilizing the aforementioned tactics, the presenter explained, all sorts of information would be vulnerable to a hacker. The risks include, but are not limited to:

Loss of financial cash flow

Permanent loss or corruption of electronically protected health information

Temporary loss or unavailability of medical records

Damage and loss of physical assets

Damage to reputation and public confidence

Threats to patient safety and privacy

Threats to employee safety and privacy Additionally, this expert of 20 years reminded that all health providers and health plans are legally obligated under HIPAA to incorporate cybersecurity measures and can receive fines, penalties, etc. for failing to do so even if no data breach occurs.

Modern considerations

He urged that viewers keep in mind the ever-broadening Internet of Things (IoT) which includes smart watches, refrigerators, cars, smart TVs, and even doorbells and coffee makers. “As these Internet of Things start showing up in your office, and [staff] are connecting them to your network, you have to be aware that it creates a whole new layer of threats that we’re not really used to dealing with.” He advised doubling down on traffic monitoring of your network for IoT devices.

An especially fresh factor is the growing telemedicine practice of 2020 as a result of COVID-19. Mr. Daigrepont warned that lack of encryption or perhaps even having Alexa listening in the background could risk exposure of private patient information discussed in telehealth sessions.

How to minimize security threats in 2020

The presenter listed several practices that should be employed for adequate threat minimization. Encryption, audits, firewalls, backup servers (particularly with many things being on the cloud nowadays), anti-virus software, and frequent software updates were among those listed.

He also recommended carrying out security risk assessment by identifying threats and vulnerabilities and coming up with a plan to protect your data, and finally to seek cybersecurity insurance that will provide resources and tools for this.

“Almost all ransomware attacks rely on poor judgement.” Mr. Daigrepont shrugged off this final piece of guidance for us. “I wish I could tell you today there was software to prevent poor judgement…We just have to be mindful.”

by Sam McCommon Ophthalmic Imaging Light-Speed Into the Future

Technology moves fast these days. That’s no secret nor a shock to anyone. But some sectors within technology move blisteringly fast — so fast that it’s a challenge for even experts in the field to consistently keep abreast of new developments. Such is the case with ophthalmic imaging, which is in the middle of what appears to be exponential growth in power and capabilities.

Imaging technology was the focus of a discussion on the second day of the AAO 2020 Virtual conference. Describing all of the information presented would take significantly more space than we have here, so we’ll focus on two aspects discussed: the increasing capabilities of artificial intelligence (AI) in imaging and the intrasurgical use of imaging technology.

AI In OCT Imaging: Deep learning shows promise

Watson team in Australia — and there were some surprises. Most notably, the team compared traditional methods of using machine learning to glaucoma — in which parameters and assumptions are given to the AI — to “agnostic” AI, which is fed the entire dataset with no set parameters or assumptions.

What they found was that the agnostic algorithm performed better than the preprogrammed one, meaning that there’s lots to be learned from deep learning tools.

The team applied the same concept to predicting visual fields from OCT data. The result? The agnostic algorithm achieved an overall estimation error of only 2% compared to the 5% they experienced using conventional biomarkers.

In one further step, the team tested deep learning algorithms to forecast retinal nerve fiber layer (RNFL) thickness and compared it to using conventional regression models. Yet again, the deep learning algorithm outperformed the conventional methods. Dr. Schuman suggested this may indicate there’s untapped data hidden in OCT images that we aren’t yet aware of. This indicates that the AI’s success is possibly due to this hidden data. For now, we’re just beginning to learn where to look — but we’re definitely learning that we can learn from deep learning algorithms.

Four-dimensional MIOCT for subretinal surgery

Let’s begin with a noncontroversial statement: It’s important for a surgeon to know what they’re doing. Being able to see what they’re doing can be extremely valuable, especially when working in delicate places like the subretinal space.

To wit, Dr. Lejla Vajzovic provided a brief exploration of the history of intraoperative OCT. In short, it’s witnessed revolutionary change over the last decade and a half. As recently as 2009, surgeons would have to pause surgery to see a 2D image via microscope. The Zeiss Rescan was a big step forward with a heads-up display a few years later. But the last few years have seen exponential growth in the power of Duke University’s microscope-integrated OCT (MIOCT) which can vastly improve a surgeon’s ability to see their own surgery in real time.

The initial 2015 prototype used spectral domain OCT at 20 khz with no volumetric imaging; the 2019 model used sweptsource OCT at 400 khz with a 12.5 hz real-time volumetric measurement rate. The higher the frequency, the better the image. So, to call this progress a step forward is...well, an understatement.

But the next generation of 4D MIOCT will blow all that away. It’s integrated with a graphic processor unit (GPU) to display real-time 3D imaging with nearreal time volumetric control. The SS-OCT can be displayed side by side with the microscopic image, meaning surgeons will have more depth-related information while performing maneuvers. The image can be rotated with a foot pedal during the surgery.

Oh, and in case you’re curious, the 4D refers to measuring volume over time — since time is the fourth dimension and all that.