Retreatment, Relationships and Regimens at AAO 2019

CONFERENCE HIGHLIGHTS

AAO 2019 Posters Hot Topics Retreatment, Relationships and Regimens at AAO 2019

by Brooke Herron

The Refractive, Glaucoma and Cornea Subspecialty Days at the recent American Academy of Ophthalmology (AAO 2019) annual meeting were chock full of new research, including updates on treatment and ongoing studies.

Below, we’re presenting some of the anterior segment highlights from the meeting’s exciting scientific program.

CIRCLE Enhancement After Myopic SMILE

It’s clear that small incision lenticule extraction (SMILE) is gaining popularity in the refractive sphere. However, enhancement using re-SMILE is neither approved nor commercially available on the VisuMax platform from Carl Zeiss Meditec (Jena, Germany), and very little data exists on its safety and efficacy. As a result, alternative enhancements like surface ablation, cap-to-flap conversion (using the CIRCLE program) and thinflap laser-assisted in situ keratomileusis (LASIK) have been proposed and established as retreatment options.

Looking further into one of these methods, Dr. Jakob Siedlecki discussed the advantages and disadvantages of CIRCLE retreatment after SMILE, which converts the SMILE cap into a femtosecond LASIK flap. (Note: While the CIRCLE software is integrated into the VisuMax platform, it is not currently available in the United States.)

There are four CIRCLE patterns with different sequential laser cuts available, although Riau et al., found that pattern D was the easiest to lift. And this step-by-step surgical technique was described by Dr. Siedlecki.

Results from a study comparing CIRCLE with other retreatments were presented. It was found that CIRCLE after SMILE provides outcomes noninferior to surface ablation. And CIRCLE was also non-inferior in terms of safety and efficacy when compared to LASIK retreatments.

Another study by Siedlecki et al., found comparable results for both CIRCLE and surface ablation at three months, while CIRCLE retreated eyes showed a markedly quicker visual recovery. CIRCLE is also easy to use and requires less preoperative planning than thin-flap LASIK above the SMILE interface. Additionally, the painless nature of the procedure may also appeal to patients, especially in conjunction with a quicker visual recovery.

However, a disadvantage of the CIRCLE approach is that it sacrifices the

Relationships ain't easy: Glaucoma (and its medications) can exacerbate problems in the cornea.

idea of the flap-free approach, which is often touted as a primary benefit of SMILE. In fact, when the anterior stroma is separated above the flap from the posterior corneal structures, more biomechanical weakening is induced than in surface ablation or in thin-cap LASIK. Dr. Siedlecki said this will be especially pronounced in deep caps: “In these cases, thin-flap LASIK anteriorly to the SMILE interface might provide better outcomes.”

This led Dr. Siedlecki to conclude that “CIRCLE offers an easy to use, safe and efficient option for refractive enhancement after SMILE. And from a surgical prospective, cap thickness of the primary SMILE procedure might be the most prominent guiding factor”.

Medication and Laser Therapy in Glaucoma Patients with Corneal Disease

At times, relationships can be complicated. And the interaction between glaucoma and the cornea is especially complex. Dr. Keith Barton explained the ties between the two, and how their relationship can affect both treatment and visual outcomes.

Firstly, glaucoma medication thins the cornea, which can cause a slight underestimation of intraocular pressure (IOP). He said there is some evidence that glaucoma medication (especially prostaglandin agonists or PGAs) results in a small amount of corneal thinning. One study reported a 6.9µm reduction in central corneal thickness after six weeks on travoprost. And another reported that the rate of central corneal thickness thinning was greater in patients who took PGA monotherapy. However, in either study, the change was not sufficient enough to impact clinical decision making.

Ocular surface disease is another consideration. Ocular surface disease is common in the age group that develops glaucoma, with 14.4% of patients experiencing dry eye symptoms. Moreover, the drugs and preservatives in glaucoma medication exacerbate ocular surface disease. Not only that, glaucoma medication can actually cause cornea and ocular surface disease. For example, allergies to topical carbonic inhibitors may develop after years of treatment, while toxicity to medication could result in dystrophic corneal epithelium and conjunctival fibrosis. Dr. Barton continued that elevated IOP reduces the endothelial cell count – with glaucoma being the single biggest risk factor for corneal transplant failure (according to the Australian graft registry). Not only that, glaucoma may also exacerbate corneal endothelial cell loss.

However, he added that early laser may protect the ocular surface and endothelium against the long-term affects of medical therapy. According to the recent Laser in Glaucoma and Ocular Hypertension (LIGHT) Trial, clear benefits of selective laser trabeculoplasty over medical therapy in newly diagnosed, medication-naïve ocular hypertension and glaucoma patients were demonstrated.

Finally, Dr. Barton explained that in recalcitrant cases, laser may be an alternative to incisional surgery. “Cyclophotocoagulation (CPC) is not new, but there are now many options, either under development or approved, than have been previously available,” he concluded.

Crosslinking for Infectious Keratitis

Introduced in 2003, corneal collagen crosslinking (CXL) is used to stabilize the progression of keratoconus. Although it’s also been performed in cases of bullous keratopathy, corneal melting, and infectious keratitis.

According to Dr. José Gomes: “The increasing number of publications on CXL treatments for infectious keratitis led cornea specialists to adopt the term ‘PACK-CXL’ (or photo-activated chromophore for keratitis-CXL)”. He said the first clinical descriptions of PACK-CXL in treating bacterial infectious keratitis were promising, with a reduction in central stromal infiltrates and melting. While similarly, other publications demonstrated good outcomes of adjunct CXL and antimicrobial topical medication in nonresponsive corneal infectious ulcers. Various other studies reported on additional advantages, including a lower rate of perforation or recurrence of infection, and corneal epithelial defect and infiltrate resolution occurring faster after CXL.

Dr. Gomes concluded that “PACK-CXL seems promising in the management of infectious keratitis, notably bacterial keratitis, and is not indicated in herpetic corneal disease”. Overall, the AAO 2019 anterior segment subspecialty days offered delegates the latest information on the most promising treatments for conditions affecting vision in the front of the eye – all in the name of preserving and maintaining eyesight for hundreds of thousands of patients around the world.

Editor’s Note: The American Academy of Ophthalmology’s (AAO 2019) annual meeting was held from October 12 to 15, 2019, in San Francisco, California, USA. Reporting for this article also took place at AAO 2019.

AIOC 2020 Preview CONFERENCE HIGHLIGHTS Set your Sights on India for AIOC 2020

Pack your bags for AIOC 2020!

by Brooke Herron

The 78 th Annual Conference of the All India Ophthalmological Society (AIOS) – AIOC 2020 – will take place in Gurugram, Haryana, India, from February 13 to 16, 2020. More than 8,000 delegates are expected to attend from India and around the world. Dr. Rajesh Sinha, who serves as the AIOS honorary treasurer, says: “The annual AIOS conference is one of the leading scientific events in the field of ophthalmology, and we are continuously striving to deliver a better conference experience to delegates each year”. Evidence of this is shown in the exuberant scientific program, with many world-renowned guest speakers on-hand to share the latest updates in all things ophthalmology. For example, some not-to-be-missed instructional courses include complicated cataract surgery cases, a tutorial in oculoplasty, diagnosis and management of chorioretinal inflammatory diseases, maximizing outcomes in phakic IOLs, customizing keratoplasty, clinical pearls in uveitis, plus many, many more. Meanwhile, master instruction classes offer methods to manage subluxated lenses and phacoemulsification complications.

AIOS Honorary General Secretary Dr. Namrata Sharma says attendees can expect the best in terms of scientific content. “The conference will include discussions on a wide array of topics in ophthalmology, as well as its newer aspects... truly living the theme of ‘Global Ophthalmology Beyond 2020’”. Several ‘Special Sessions’ will also take place at AIOC 2020, such as the President’s Guest Lectures, and National Symposiums on topics including small incision cataract surgery (SICS), kerato-refractive surgeries, pediatric ophthalmology, ocular trauma and practice management. International symposiums about anterior segment imaging, surgical innovation in glaucoma, genetics in ophthalmology and post-surgical endophthalmitis are additional conference highlights that should not be missed.

Of course, AIOC would not be complete without its prestigious awards, including the P. Siva Reddy International Award (jointly awarded to Dr. Suven Bhattacharjee and Haripriya Aravind for the B-HEX Pupil Expander and for endophthalmitis reduction with intracameral moxifloxacin, respectively), and the CN Shroff Award (awarded to Dr. Rajiv Raman for work in vitreoretinal diseases). Numerous awards will also be presented to the best free papers, poster, podium presentations and more. This year will also welcome new AIOS President, Dr. Mahipal Sachdev. “Often described as a living legend in ophthalmology, Dr. Sachdev is sure to take AIOS to new heights with his passion and commitment, his knowledge and sheer brilliance, his zeal and enthusiasm and his leadership and team spirit qualities.”

Held in Gurugram, known as the Millennium City of Haryana, at the A Dot Convention Center GNH, AIOC 2020 will be just a 5km drive from the Delhi airport, making transport simple for national and international delegates. Gurugram is known as a financial and technology hub and features various attractions, such as national parks, museums, theaters, temples and more. With such a robust scientific program, with leading experts from around India and the world, AIOC 2020 promises to be the biggest yet. And with continued innovation, research and collaboration at conferences such as this, the understanding, management and treatment of ophthalmic conditions are updated and advanced, ultimately resulting in better visual outcomes for all.

Editor’s Note: Media MICE Pte Ltd, CAKE magazine’s parent company, is the Official Media Partner of AIOC 2020.