At Press Time

ASCRS Studies Collaborative Care Model

Integrating the efforts of MDs, ODs and staff.

■ ASCRS has formed an Integrated Ophthalmic-Managed Eye Care Delivery (IOMED) Task Force to investigate and recommend ways in which the organization and its membership can act to advance an eyecare delivery model based on a synergistic collaboration between optometry and ophthalmology.

The IOMED Task Force includes three representatives from ophthalmology and five from optometry, and is chaired by ASCRS governing board member Stephen S. Lane, MD.

In addition to completing a comprehensive membership needs assessment, the IOMED task force will consider creating new educational tracks at the ASCRS annual symposium as well as an entirely separate society designed to meet the educational needs of integrated eye care practitioners.

The IOMED model, which is endorsed by the ASCRS executive committee and governing board, encourages arrangements in which optometrists employed by ophthalmologists, as well as optometrists employed by the military or industry, play a key role in the delivery of nonsurgical eye care.

This patient-centered model encourages greater efficiency and coordination of care with ophthalmologists and optometrists working together to meet the growing demands for service and address the pending changes in Medicare and general healthcare delivery. The task force is expected to make formal recommendations to the ASCRS leadership in the coming months.

“The goal of the task force is to find and present the best possible ways to facilitate cooperation between ophthalmologists and optometrists so that we are prepared to meet the needs of the 77 million American Baby Boomers nearing the age of 65,” said Dr. Lane. “Today, and in the future, high-quality eye care will require a patient-centric, integrated model in which ophthalmologists, optometrists, technicians, opticians and managers work together in a dynamic setting.”

As a step toward achieving that cooperation, in April ASCRS announced the establishment of a new membership category that will enable certain optometrists to apply for membership to the organization for the first time.

To be eligible for membership, optometrists must be employed by an ASCRS member who is a board-certified ophthalmologist. The new membership category, which emphasizes a working partnership between ophthalmologists and optometrists, supports the concept of the integrated model.

Stents Effective With Baerveldt Shunts

Excellent IOP reduction achieved.

■ The systematized use of intraluminal stents in Baerveldt shunts can control IOP with minimal hypotony-related incidence, according to a study presented by Swiss researchers at the ARVO 2012 meeting. The study focused on 120 eyes with medically uncontrolled glaucoma. The aim was to investigate the effects of intraluminal stents in Baerveldt shunts on early, postoperative IOP control. The study also noted complication rates.

Baerveldt shunts were stented using a Supramid 3.0 suture. Of those, 37% were ligated intraoperatively and had laser suture lysis performed postoperatively. Mean preoperative IOP was 26.9 mm Hg. At one year, 87% of studied eyes had an IOP less than or equal to 21 mm Hg and a minimum of 20% IOP reduction from baseline was achieved. Complete stent removals were performed in 61% of eyes and partial removal in another 24%. Thirteen percent of the eyes required no stent removal to achieve targeted IOP. Complications were found in 16% of eyes but only 7% were hypotony related. The mean age of patients participating in the study was 61.8 years and their mean follow-up was 17.1 months.

Reference:

Cyrielle H. Bela et al. Systematized stenting of Baerveldt shunts: techniques to reduce early postoperative hypotony. ARVO 2012 (abstract).

‘Glaucoma Day’ Helps Communication

Medical professionals and patients exchange views.

■ It may not be as fun as New Year's or even crazy hat day, but one study has shown Glaucoma Patient Day can be a valuable service to both patients and healthcare professionals.

By conducting a Glaucoma Patient Day attended by almost 300 medical professionals, patients and patient advovates, Ananth C. Viswanathan and a team of patient advocates at Moorfields Eye Hospital in London were able to consult with patients, address their concerns, answer lingering questions and receive feedback.

Patients reported quality of life was most affected by fear of losing vision (46%) and the impact on driving (14%). The researchers also point to valuable patient feedback involving medications and sideeffects. According to the feedback, latanoprost was the best-tolerated ocular hypotensive eye drop. Patients reported the question-and-answer session to be the most valuable in addressing fears and concerns.

As a result of the one-day event, the Moorfields Glaucoma Research Community was created. The community involves more than 100 patients who registered an interest in being involved in research design, management conduct and dissemination of results.

Reference:

Ananth C. Viswanathan, et al. Glaucoma Patient Day: Involving patients, improving care, prioritizing research. ARVO 2012 (abstract)

Research Digest

New & Noteworthy Journal Articles

Compiled by Andrew E. Mathis, PhD, Medical Editor

► Cornea fellows performing DSAEK. How well do cornea fellows perform DSAEK? A team of surgeons in Iran examined the issue, reporting their findings in the September 2012 issue of Cornea. The study enrolled 78 eyes of 73 patients with corneal endothelial dysfunction and submitted them to DSAEK performed by four cornea fellows under the supervision of experienced faculty members.

The mean postoperative logMAR BCVA at six months was 0.77, an improvement from 1.8 before surgery. Mean central corneal thickness was 709.09 ±109.24 µm at six months, and the mean endothelial cell density was 1,180/m2, representing a loss of 61%. Thirty-five cases saw complications, including lenticle detachment in 17 and graft failure in eight.

The report was only the second assessing cornea fellows' surgical performance, the first having been conducted in the United States in 2009.

► OCT in glaucoma. Progression of glaucoma often is associated with optic disc hemorrhage. However, previous attempts to define this relationship, using various types of imaging technologies, have had inconsistent results. The August 2012 issue of the Journal of Glaucoma features an article applying OCT to clarify this complex relationship.

Examining 44 eyes with unilateral disc hemorrhages and their 44 fellow eyes and following them up for an average of almost 40 months, the study authors found that almost three-quarters of the eyes with hemorrhages showed progression of glaucoma on OCT, compared to slightly more than one-quarter in the control group. The vast majority of eyes with hemorrhages (more than 90%) showed progression with one clock hour of the hemorrhage.

The study showed that after a disc hemorrhage is first seen on OCT, rapid, localized, spatially compatible loss of the retinal nerve fiber layer can be detected, and this thinning coincided with the area of hemorrhage.

► Depression and glaucoma. In addition to its devastating effects on vision, glaucoma can take an emotional toll as well. Doctors at the University of California, San Francisco, in an article, published online in July by the American Journal of Ophthalmology, studied the risk factors for depression in patients with glaucoma.

The authors administered the PHQ-9 questionnaire, an instrument designed to measure symptoms of depression, to 6,760 patients who were enrolled in the National Health and Nutrition Examination Survey, as well as submitted them to visual field testing, VA examinations and fundus photography. They found a 10.9% rate of depression among glaucoma patients vs. 6.9% among those subjects without the disease.

The association between glaucoma and depression was significant, but not after adjustment for self-reported health factors. In short, objective measurements of vision were not a significant predictor of depression, but self-reported symptoms were. The authors suggest that influencing patients' perceptions of the disease could affect their emotional well-being.

► New procedure for dropped lenses. Dropped lens fragments are a frequent complication of phacoemulsification. In the August 2012 issue of the British Journal of Ophthalmology, a Japanese team of physicians reported on a new surgical technique to remove these fragments.

In a small series of six eyes from six patients, the BJO authors removed dislocated lens nuclear fragments by inserting an anterior vitreous cutter with an endoillu-minator into the eye, through the pre-existing incision for phaco, and performing core vitrectomy. Then, a Fragmatome, also with an endoilluminator, was used to grasp the dropped fragments, which moved to the anterior chamber for division and removal.

The procedure is attractive because it avoids the three ports normally required for small-gauge vitreoretinal surgery, instead using the sclerocorneal incision made for phaco.

► Anti-VEGF for cornea. The September-October 2012 issue of Survey of Ophthalmology featured an important review of the data on the use of anti-VEGF drugs in corneal neovascularization. The authors, doctors from the Illinois Eye and Ear Infirmary, covered drugs that are FDA-approved (Lucentis, Eylea), used off-label (Avastin) or under investigation (siRNA).

The authors reviewed nearly 50 articles in the literature on investigations of anti-VEGF agents for conditions that can result in corneal neovascularization, including keratitis, bacterial and fungal infections and trauma. They also discussed the more recent use of VEGF blockade in corneal transplantation.

They closed by discussing possible future directions in the treatment of corneal neovascularization, including anti-PDGF agents and combination therapies that employ anti-VEGF drugs. Given that no anti-VEGF drugs are currently approved for this condition, the authors recommend large, prospective clinical trials.

► Myopia in children. Collaborating between Ohio and Alabama, a team of optometrists studied the percentages of new cases of myopia in children five to 16 years old between 1989 and 2009. Archives of Ophthalmology published their findings online in June.

Nearly 5,000 children across five racial/ethnic groups were studied over the 20-year period. A large majority (92.5%) were not nearsighted at the start of the study, but 749 (16.4%) children were diagnosed with new cases of myopia during the study, with the largest number being diagnosed at 11 years old.

Retina Roundup

Timely and Important Retina News of Interest to All Ophthalmologists

Compiled by Andrew E. Mathis, PhD, Medical Editor

► Early AMD treatment. Does how quickly a patient receives treatment with Lucentis for wet AMD have any effect on visual outcomes? To answer this question, retinal physicians in Austria undertook a retrospective study, publishing their findings in the July 2012 issue of Retina.

The researchers divided 45 patients into three study groups based on the length of their symptoms. The study authors found that the shorter the disease duration was, based on the presence of visual symptoms, the better the visual outcomes were with two monthly intravitreal injections of Lucentis. Patients with longer intervals before treatment still improved but not as much.

The authors concluded that significantly better outcomes in BCVA are found when treatment with Lucentis begins within one month of symptom onset. They recommend treatment as early as possible, with the typical three loading doses used in many retina practices.

► Retreatment with Lucentis. An ongoing controversy with Lucentis therapy for wet AMD is when to retreat. An article published online in June by Graefe's Archive of Clinical and Experimental Ophthalmology provides more data on this question.

Doctors in Lausanne, Switzerland, enrolled 39 treatment-naive patients with wet AMD and gave them three loading doses of Lucentis. Then, a stepwise approach was used to determine the need to retreat, based on the presence of subretinal fluid or an increase in central retinal thickness.

After follow-up of one year, an average of 7.5 injections were administered to the patients, and the patients' VA had improved by a mean of 12.6 ETDRS letters. From their statistical analysis, the authors concluded that the first interval before retreatment was a good predictor of the second retreatment interval and that the retreatment criterion in each patient remained the same 97% of the time.

While they were unable to recommend a new treatment regimen for Lucentis, the authors suggested their findings could best be used in developing individual treatment plans for AMD patients.

► Personalized AMD treatment. Speaking of the personalization of treatment for AMD, an editorial in the September 2012 issue of the American Journal of Ophthalmology, by a pair of ophthalmologists from France, addressed this issue.

Arguing for a genetic approach to treatment for wet AMD, the authors covered the most recent findings from genetic studies of AMD patients. Based on these elucidated correlations between genes and disease states, they argued that pharmacological treatments for AMD could be targeted to specific genotypes, drawing parallels between medical retina and oncology and cardiology protocols that have been based on genetics.

Given that vitamins will not prevent AMD in patients carrying a certain genotype, the authors indicated the need for such an approach. This method of treating patients with AMD, they said, could ultimately lead to customized AMD treatments.

► Avastin for CNV in high myopia. Avastin is clearly effective in resolving choroidal neovascularization (CNV) in patients with wet AMD, but what about in patients with CNV from causes other than AMD, such as high myopia? In an article in the August 2012 issue of the British Journal of Ophthalmology, a study team from Italy reported on their prospective trial of 30 patients with this problem.

Treating 32 eyes from these 30 patients with three monthly intravitreal injections of Avastin, the three-year results were impressive. Mean BCVA improved by more than 15 ETDRS letters, along with a statistically significant reduction in the area of CNV.

The authors conclude that three monthly Avastin injections constituted an effective and sustainable treatment for CNV due to high myopia, particularly among younger patients with better baseline BCVA. Although the study was small, it is powered by its length of follow-up and prospective nature.

► OCT in AMD. Retinal physicians have been using OCT to track patients with AMD for years now, but how well they interpret these images is subject to debate. Ongoing issues in OCT image interpretation are covered in an article in the September-October 2012 Survey of Ophthalmology.

The authors, who collaborated among six treatment centers, believe that the rapidity with which OCT technology has developed and the heterogeneous nature of the AMD disease process render the process of reading OCT images properly a difficult one. Furthermore, tracking of dry AMD is difficult with OCT.

The authors hope that this review will provide a handy reference for ophthalmologists in practice. They are hopeful that the ability to read OCT properly will eventually catch up to the technology.

► BOLT trial results. As Lucentis has recently received FDA approval for the treatment of diabetic macular edema, Avastin has also undergone clinical testing in DME. The August 2012 Archives of Ophthalmology included the two-year data from the BOLT trial, conducted in the United Kingdom and Australia.

The study authors found that the patients in the study gained a median of nine ETDRS letters in VA vs. 2.5 letters gained for macular laser therapy, which was administered to a control group. Far more patients receiving Avastin gained at least 10 or 15 letters, and all of the Avastin patients lost fewer than 15 letters (vs. 86% in the laser arm). The mean number of injections was four.

Preview of AAO 2012

Abraham Verghese, MD, MACP, will present this year's keynote address.
By Bill Kekevian, Associate Editor

The American Academy of Ophthalmology is gearing up for this November's joint meeting in Chicago. As in years past, ophthalmologists from across the globe will converge in the Windy City to share advances, techniques and opinions. Abraham Verghese, MD, MACP, is slated to give the keynote address at the opening session on Sunday, Nov. 11. Dr. Verghese is a professor at Stanford University's School of Medicine. He has also published three books, including a novel that spent 100 weeks on the New York Times bestseller list. As a patient advocate, he has appeared on NPR and CBS's “60 Minutes.”

The meeting will be replete with special events, long lectures, and short subspecialty presentations. Here are a few standouts:

■ Joan Miller, MD, a retina specialist, pioneer in the treatment of wet AMD and chief of ophthalmology at Massachusetts Eye and Ear at Massachusetts General Hospital, will also highlight the opening session with this year's Jackson Memorial Lecture Monday Nov. 12 at 8:13 am.

■ Gunther Grabner, MD — Barraquer Lecture: 30 Years of Refractive Surgery—A Critical Analysis With an Optimistic Outlook. LASIK Is Safe: Prevention and Management of Laser Complications: Combined meeting with the International Society of Refractive Surgery (ISRS) Sunday, Nov. 11 3:45 pm.

■ Jack T. Holladay, MD MSEE FACS — Charles D. Kelman Lecture. Spotlight on Cataracts: Clinical Decision-making With Cataract Complications Monday, Nov. 12 8:15 am.

■ William L. Rich, MD — Parker Heath Lecture: Electronic Health Registries for Ophthalmology: The Big Picture. Re-engineering the U.S. Health Care System: The Impact on Ophthalmology: Combined meeting with the American Medical Association Ophthalmology Section Council Monday, Nov. 12 8:30 am.

■ Robert L. Stamper, MD — Robert N. Shaffer Lecture: Today's Glaucoma Challenges and What You Can Do About Them Advances in the Surgical Management of Glaucoma: Combined meeting with Prevent Blindness America, Inc. Mon. Nov. 12 10:15 am.

Subspecialty day lecturers will tackle a number of topics from developments in refractive surgery to EHR requirements in brief presentations. Here's a look at some:

Cornea: Saturday, November 10th - McCormick Place Grand Ballroom S100ab

■ Stephen C. Pflugfelder, MD — New Tests for Dry Eye: Should I Incorporate Them Into My Practice? 8:15 am.
■ David F. Chang, MD — Pars Plana Vitrectomy for the Anterior Segment Surgeon 11:25 am.
■ Theo Seiler, MD PhD— Dohlman Lecture: Crosslinking in the Year 20/20: What Will the Future Hold? (with introduction by Kathryn A. Colby, MD PhD) 2:10 pm.
■ Anthony P. Adamis, MD — Making the Move to Industry: Why the Brightest Minds Have Gone to the Dark Side 3:07 pm.
■ Mark A. Terry, MD — Endotheial Keratoplasty Mythbusters: When “Common Knowledge” is Wrong. 4:15 pm.
■ Gerard Sutton, MBBS — Femtosecond Laser-assisted Cataract Surgery: Lessons from the Learning Curve. 4:55 pm.

Glaucoma: Saturday, November 10th - McCormick Place, Room E354

■ Sanjay G. Asrani, MD — Pitfalls in Interpreting Spectral Domain OCT 8:45 am.
■ David S. Greenfield, MD — How I Treat Patients Progressing at Low IOPs 9:39 am.
■ Paul J. Foster, FRCS — Could Your Primary Open-Angle Glaucoma Patient Have Chronic Angle Closure? 10:48 am.
■ Marlene R. Moster, MD — The Glaucoma Filtration Device Mini-shunt Has Been a positive Development 1:51 pm.
■ Robert M. Feldman, MD — The Glaucoma Filtration Device Mini-shunt: I Don't Get It 1:57 pm
■ Brian A. Francis, MD — The Use of Intraoperative Endoscopy 3:59 pm

Refractive Surgery: Friday, November 9th and Saturday, November 10th - McCormick Place, Hall B

Friday:
■ Richard L. Lindstrom, MD — LASIK Enhancement Techniques 9:43 pm
■ Minoru Tomita, MD PhD — Simultaneous LASIK and Implantation of an Intracorneal Inlay 2:36 pm
Saturday:
■ William W. Culbertson, MD — Technique Pearls for Success in Laser Refractive Surgery 2:06 pm
■ Stephen G. Slade, MD FACS — Can Laser Refractive Len Surgery Really Work for You and Your Practice? 3:11pm
■ Thomas M. Harvey, MD — Phakic IOLs: Tips and Techniques 4:54 pm

Retina: Friday, November 9th and Saturday, November 10th - McCormick Place, Arie Crown Theater

Friday:
■ David W. Parke, MD— The Future of Health Care: Survival of the Fittest 4:14 pm
■ William L. Rich, MD — Accountable Care Organizations: In or Out? 4:21 pm
Saturday:
■ David S. Boyer, MD— Long-Term Delivery Strategies for Neovascular AMD 9:22 am