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Experts figure out how to make endothelial keratoplasty less complicated

Advanced Endothelial Keratoplasty, Making it Less Complicated

by Olawale Salami

On the second day of AAO 2020 Virtual, experts convened (virtually, of course!) to discuss the overview and surgical pearls on advanced endothelial keratoplasty. Here are some of the highlights...

DMEK: Avoiding surgical entanglements

“Overall, DMEK is the next generation of lamellar surgery. It is challenging but feasible in most patients, and with care, many of the complications seen before, during, and after surgery can be avoided,” said Dr. Brandon Ayres, codirector of the cornea fellowship program of the WillsEye Hospital in Philadelphia (USA).

In his presentation, Dr. Ayres shared important tips on how to avoid complications associated with DMEK surgeries. He said that proper patient selection is the best way to avoid complications of DMEK (Descemet’s membrane endothelial keratoplasty). “Keep it simple for the first several cases, and make sure you have a pseudophakic patient with an IOL in the bag and mild-to-moderate corneal edema,” noted Dr. Ayres.

It’s important to stay away from patients with tubes, crowded anterior chambers and post vitrectomy cases, according to Dr. Ayres. “In addition, to reduce the risk of rejection, try to select patients

who can lie reclined for a few days to allow graft attachment,” he said.

Intraoperative complications of DMEK can occur at several steps: from the graft preparation, insertion, donor unfolding or visualization. Postoperatively, graft detachments will happen, and except if they are large, these can be ignored. Infectious keratitis remains a significant risk postoperatively.

Is DMEK superior to DSAEK?

“Eyes with good anterior chamber views, normal anatomy and potential for VA of 20/20 are ideal candidates for DMEK,” said Dr. Massimo Busin, professor of ophthalmology, University of Ferrara (Italy).

During his presentation, Dr. Massimo Busin reported that over the past decade, DMEK has gained increasing popularity with over ten thousand cases performed in 2019. “I have advocated that the choice of an operative procedure selected should be based on the preoperative status of the patient and eyes with good anterior chamber views, normal anatomy and potential for VA of 20/20 are ideal candidates for DMEK,” he shared.

“In order to simplify the procedure for new surgeons or those just transitioning from Descemet stripping automated endothelial keratoplasty (DSAEK), I recommend the bimanual pull through maneuver,” he added. In a review by the American Academy of Ophthalmology, the authors concluded that DMEK was superior to DSAEK. However, this assessment did not consider the fact that DSAEK has evolved towards a use of thinner grafts, now known as UT-DSAEK, explained Dr. Busin.

“Therefore, based on data from the most current randomized controlled trials, there is no compelling evidence that DMEK is superior to UT-DSAEK, especially for complex eyes,” said Dr. Busin.

Artificial iris in complex DMEKs

“For more complex cases with AC abnormalities, I first reconstitute the anatomy of the chamber by removing abnormal iris, reestablishing the posterior surface of the AC with the artificial iris,” said Dr. Donald Tan, Arthur Lim Professor at the Singapore National Eye Centre (SNEC) and DukeNUS Medical School (Singapore), when he discussed how he has perfected the use of artificial irises in the management of complex DMEK cases.

“My current DMEK technique involves a pull through endo-in DMEK technique using the DMEK endoglide donor inserter, which goes through a 2.7mm clear corneal wound,” shared Dr. Tan.

“The clinical trial which we published involved 69 eyes, in which the mean endothelial cell loss was about 33%. This approach provides for enhanced control of the anterior chamber and facilitates DMEK performance in more complex cases,” he added.

What constitutes complex DMEK cases? Dr. Donald Tan explained that complex DMEK scenarios are those where the anterior chambers are limited by peripheral anterior synechiae (PAS), iris adhesions. In addition, there may be inadequate posterior surface of the anterior chamber. For example in aniridic eyes, eyes with dilated fixed pupils, open vitreous cavity or aphakia. There is an elevated risk of DMEK graft failure in these scenarios.

“The solution I recommend in these situations is to reconstruct the anterior chamber prior to DMEK surgery. This can be done by synechiolysis and removal of the PAS. In addition, reconstructing the posterior surface of the anterior chamber by implanting an artificial Iris. All these are performed as a separate procedure before the DMEK,” explained Dr. Tan.

Pull-through endo-in DMEK approach using the DMEK endoglide provides for enhanced donor control and a controlled chamber depth and can be used in more challenging cases. “With better surgical control we can now perform more complex cases where anterior segment and chamber abnormalities may make conventional DMEK a real challenge,” added Dr. Tan.

Managing The Rare Cancer that is Vitreoretinal

by Hazlin Hassan

Vitreoretinal lymphoma (VRL) is a rare yet challenging cancer, said Professor Justine Smith, of Flinders University, Australia, in presenting the C Stephen and Frances Foster Lecture on Uveitis and Immunology at the annual meeting of the American Academy of Ophthalmology (AAO 2020 Virtual) on Saturday (November 14).

“Vitreoretinal lymphoma is an extremely challenging disease. The condition may present quite nonspecifically or it may masquerade as a variety of other diseases including viral retinitis,” she said.

The disease, formerly known as ocular reticulum cell sarcoma and intraocular lymphoma, involves the retina, vitreous and optic nerve, and represents a subset of primary central nervous system (CNS) lymphoma. It has an estimated annual incidence of 9 per 10 million adults.

“The vast majority of patients with VRL have Non-Hodgkin’s diffuse large B-cell lymphoma, rarely T-cell lymphoma,” said Prof. Smith.

A total of 41% of patients with VRL will have brain involvement at presentation, and 69% will develop brain involvement over the course of their disease, she added.

Vitreous biopsy yields scant tissue with fragile cells. There are no consensus guidelines on staging and grading. Classic presentation includes vitreous cells, gray-white retinal lesions, and yellow-white sub-RPE lesions.

Other clues are onset in older adulthood, little anterior chamber activity, no posterior synechiae, vitreous cell outweighing haze, aurora borealis, leopard spot retinal pigmentation, lack of macular oedema, and visual acuity better than expected from examination.

There are also challenges in diagnosing VRL. Traditionally cytology combined with flow cytometry is required. However, the negative predictive value of cytology has been estimated at approximately 60%, meaning that the diagnosis is often delayed and multiple procedures may be needed.

Moving into an era when other investigations may provide diagnosis of VRL if cytology is inconclusive, means that doctors can now carry out cytokine analysis, genetic testing and ophthalmic imaging in order to diagnose the disease.

With very limited medical evidence, there are many approaches to treatments, which varies from center to center, and depending on whether the brain is involved, Most patients will ultimately develop primary CNS lymphoma and the five-year survival is 33%.

Available treatments include chemotherapy, and targeted therapy such as monoclonal antibodies and small molecules, radiotherapy, and autologous stem cell transplant.

Many chemotherapy and targeted therapy drugs are being used today namely methotrexate, cytarabine, thiotepa, rituximab, nivolumab, ibrutinib, and lenalidomide.

Induction involves multiple drugs based around high dose methotrexate. Whole brain radiotherapy is avoided due to cognitive adverse events. Consolidation may include drugs, low dose whole brain radiotherapy and autologous stem cell transplantation after myeloablation. Treatment is also given to alleviate visual symptoms, limit retinal damage and improve overall survival.

Local therapies often induce ocular remission, although recurrence rates are unclear.

The largest studies (70 to 83 patients, with multiple treatment regimens) show that overall survival is no different for local versus local and extensive regimens.

In conclusion, VRL is a rare cancer with challenges related to non-specific presentation, high rate of false negative cytology, poor survival and lack of medical evidence to guide therapy but there is an expanding armamentarium of investigations, such as cytokine analysis, genetic testing, ophthalmic imaging.

Multinational multidisciplinary collaborative efforts are fuelling progress,” Prof. Smith said. Finally, she touched on HIV-associated VRL, which has been reported in less than 20 patients ranging in age from 26 to 71 years old. HIV-positive persons have 17 times the risk of primary CNS lymphoma but the relative risk of VRL is unknown. It is often misdiagnosed as CMV retinitis. Infectious uveitis may co-exist. Treated with ART and lymphoma-focused local and/or extensive therapies will raise the CD4 count and lower the HIV viral load, leading to better survival for primary CNS lymphoma. If optimally managed, survival outcomes should approach those in HIV-negative persons, she said.

private practice? Are you already in one and need advice on how to maintain financial security? Debra L. Phairas, president of Practice & Liability Consultants, offered up some of her 35 years of experience in the physician practice management and healthcare industry. On the 2nd day of AAO 2020 Virtual we tuned in to Survival Skills to Thrive in Private Practice! to hear some of the factors she considers most important to keep in mind as a private equity ophthalmologist.

Private or employed: which is right for you?

One of the first thoughts Ms. Phairas posed was how to decide if you’re better suited for private practice or as an employed physician. She presented some questions to ask yourself when choosing between the two: control? work role happy and satisfied with the work culture?

you negotiate a 3-5 year guaranteed salary? While noting that private equity has been very popular in ophthalmology, she went over some of the pros and cons of each option primarily revolving around salary considerations. One of these considerations was that compensation negotiation is important for those moving to or staying in employment; alternatively, there was a detailed list of steps outlined to plan expenses of a private practice.

Private practice expense planning

In private practice you’ll be responsible for various aspects down to data privacy, areas of liability, and – perhaps the most touched upon by our speaker this afternoon – finances. Responsible financial practices include benchmarking, or comparing practice costs to other similar practices, and developing detailed expense categories line by line. “You need to know all of this to see… what are the ranges and percentiles; the median is what you should be probably looking at,” the expert explained. She also suggested finding ways to reduce overhead by investing in an accountant and referring to reports by

Tips to Succeed in Small Private Practice

by Elisa DeMartino

Thinking of moving into your own

How much do you like to be in

Are other physicians in the designated 4. If choosing the employment route, can

AAO and MGMA.

Merging considerations

Continuing along the topic of finances, the speaker addressed any viewers thinking of merging, which she described as a process that shouldn’t be rushed for economic, competitive, or managed care pressures.

She warned against merging too quickly just to save costs, saying “just like marriage, money is the biggest reason for a divorce and the biggest reason for why people don’t get along in practice.”

Additional things to keep in mind

Ms. Phairas threw in several more tips for “thriving and surviving” in private practice. She strongly recommended having a planned yearly budget and noted that the October-November time period we’re in now is the best time to create one for the next year.

She also reminded viewers to keep up with fine details such as turnover rate, future trends, and even office clutter that can slow down staff.

On the subject of marketing your practice our speaker suggested you forget about yellow pages and instead focus on search engine optimization and content management of your website. She added that you ought to look at consumer reports and keep an eye on your reputation on rating sites.

Final thoughts

Debra Phairas encouraged everyone that in order to survive and thrive in pirate practice, “you just have to learn some basic business development principles, some finance principles; you have to have some operations improvement knowledge and a good human resources background.” She closed her session by urging that anyone thinking of opening a private practice should, in addition to adopting this well-rounded approach, remember to take care of themselves particularly during this pandemic year.

Through the Looking Glass

IOL Updates

by Sam McCommon

No full-scale ophthalmology conference would be complete without a discussion of the newest and best intraocular lenses (IOLs), and

AAO 2020 Virtual did not disappoint.

Chairs Dr. Bobby Ang and Dr. John

Chang led the discussion, which featured not just the best and newest IOLs, but delved into the nitty gritty of techniques and featured a lengthy Q&A session. If you’re an IOL geek, this panel is mustsee TV.

Extended range of focus IOLs

Dr. Robert “Bobby” Ang guided viewers through a bit of the history of multifocal IOLs before delving into the quickly evolving world of extended depth-offocus (EDoF) IOLs. The first EDoF lens to be approved by the FDA was as recent as 2016, so this is fairly new technology indeed.

Dr. Ang explained that EDoF lenses provide a good balance between quality and quantity of vision. They give better vision for gadgets like smartphones or laptops than monofocals, even with less near vision compared to multifocals. There’s also fewer patient complaints of photic phenomena like glare and halo compared to multifocals. Overall, EDoF lenses appear to be a good compromise.

Compared to trifocals, EDoF lenses provide very good distance and intermediate vision, though wearers will likely need reading glasses. Dr. Ang noted they’re valuable for targeting mild myopia or mini-monovision.

EDoF: Small aperture IOL

Continuing with the EDoF discussion, Dr. John Vukich introduced Small Aperture IOLs as a way to produce true extended depth of focus. They’ve been available in Europe for several years, and can help neutralize astigmatism.

He described the Small Aperture design as a single piece made of hydrophobic acrylic, with a 1.36 mm aperture and 3.23 mm total diameter. It provides a broad range of vision and is tolerant to astigmatism within 1.50 D.

One important note with Small Aperture IOLs is that both fundus photography and retinal OCT are both possible. Differences are minimal compared to both monofocal and multifocal for fundus photography and multifocal for OCT.

Dr. Vukich also suggested Small Aperture IOLs are valuable for irregular corneas, including post-radial keratotomy, postkeratoconus, and post-LASIK patients.

Mix ‘n’ Match: Combining IOLs

Dr. Aylin Cilic explored the possibility

of using different IOLs in patients’ eyes to achieve balance between each IOLs strengths. By combining different lenses, patients can rely on different eyes for different tasks.

Dr. Cilic pointed out that high-add IOLs provide better near vision and worse distance vision, whereas low-add IOLs lead to better distance and intermediate vision. So, applying one each to different eyes can lead to an overall improved field of vision — assuming the patient likes the idea, of course. Overall, patient satisfaction has been high, according to a publication by Yang et al. in a 2018 BMC Ophthalmology paper.

Mixing and matching can lead to a bestof-all-worlds scenario in some cases. In addition to maximizing each lens’s best features, mixing and matching can also reduce common visual side effects of multifocal IOLs like halo, glare, and reduced visual acuity in intermediate and near ranges.

Unfortunately, there is currently no study comparing mix-and-match trifocals compared to bifocals. But if we know anything about studies, we can assume that somebody is either already planning one or is thinking about it.

Dr. Cilic concluded that the mix-andmatch with high- and low-add power lenses is an effective way to achieve good quality of vision over a broad range without affecting quality of vision. The practice also provides another option for patients who want to be free from glasses after cataract surgery.

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