March 28-30, 2009
Vail, Colorado
The annual New Horizons in Ophthalmology meeting held in Vail, Colorado this year and sponsored by Bascom Palmer Eye Institute was a fantastic meeting filled with exciting talks by ophthalmologists of various disciplines including retina, cornea, glaucoma, pediatric and oculoplastic surgery. The venue was great, the powder was fresh and the company was outstanding this year.
Educational grants from Alcon, Allergan, AMO, and Sirion Therapeutics made this continuing medical education meeting possible.
Dr. Roger Steinert
Dr. Roger Steinert kicked off the meeting with a talk entitled "Problem Solving with Presbyopia Correcting IOLs". He presented algorithms for how to deal with broken capsules during cataract surgery, and how to deal with patients complaining of poor vision post cataract surgery, including tips for how to deal with halos and glare. His take home points from the lecture were:
1. "Only implant a presbyopia IOL in a patient who prioritizes functional vision without glasses."
2. "The patient must both hear and understand that the goal of the presbyopia IOL is a wider range of functional vision without glasses, and that glasses may still be needed for a few particular activities."
3. "Do not place a multifocal IOL in an eye that already has compromised visual function from another source."
4. "Remember that you are now a refractive surgeon."
Dr. Steinert's next talk entitled 'Current Results with Zig-Zag Femtosecond Laser-Enabled Keratoplasty' concluded that this laser and DSEK may lead to decreased total higher-anterior corneal aberrations compared to conventional penetrating keratoplasty and that DSEK resulted in the least amount of higher-order anterior corneal aberrations. The femtosecond laser "Zig-Zag" incision provides more rapid BSCVA recovery and less induced astigmatism compared to conventional trephination PKP.
Dr. Ninel Gregori
Dr. Ninel Gregori presented on 'Endophthalmitis After Cataract Surgery'. Take home points include: 4th generation FQs do not prevent endophthalmitis. Incidence of endophthalmitis with clear corneal surgery is very low. Although intracameral antibiotics have shown to be beneficial in the ESCRS study, there are many associated risks. Endophthalmitis may present on POD 1+. Endophthalmitis after clear corneal cataract surgery may present later than ECCE. Gram (-) organisms may cause delayed onset endophthalmitis after cataract surgery. Amphotericin B is still the preferred first line agent for fungal endophthalmitis.
Dr. Gregori also presented 'Anti-VEGF Therapy for Macular Edema Secondary to Retinal Vein Occlusions'. She concluded that Va and OCT improve with anti-VEGF injections at least for one year and visual results may be better than with laser. No direct comparison of laser vs. anti-VEGF injections is available. Multiple frequent PRN anti-VEGF dosing may be necessary to achieve a fluid-free macula. An ischemic, non-perfused macula may improve anatomically but Va may not improve after an anti-VEGF challenge. Ranibizumab prospective studies are underway (CRUISE, BRAVO). Bottom line: for retinal vein occlusions begin treatment as soon as possible. VEGF induces endothelial cell proliferation leading to capillary non-perfusion and greater ischemia leading to higher VEGF levels (a vicious cycle).
Dr. Steven Gedde
Dr. Steven Gedde presented 'The Tube Versus Trabeculectomy'. He concluded that tube shunt surgery was more likely to maintain IOP control and avoid persistent hypotony, reoperation, or loss of light perception than trabeculectomy with MMC during the first 3 years of follow-up. Both procedures had similar IOP reduction and use of supplemental medical therapy at 3 years. There was a trend toward a higher rate of reoperation after trabeculectomy with MMC compared with tube shunt surgery. Early postoperative complications occurred more frequently after trabeculectomy with MMC than tube shunt surgery. The rates of late postoperative complications were similar for both surgical procedures. There was no difference in the rate of vision loss following either procedure. Cataract progression occurred with similar frequency with both procedures.
His next presentation, 'Pearls and Myths From Clinical Trials in Glaucoma' summarized from multiple studies the following: Lowering IOP by ≥30% in patients with OAG delays or prevents worsening of glaucoma. Lowering IOP by <30% results in greater rates of progression of glaucoma. It is a myth that all glaucoma patients should have IOP<18mmHg and/or an average IOP=12.3mmHg to prevent progression. Lowering IOP by 20% in patients with ocular hypertension reduces the risk of developing POAG by half. Always repeat the VF if you suspect a new or progressive defect when following a glaucoma patient or ocular hypertensive. Some epidemiologic studies show diabetes as a risk factor for glaucoma, but none indicate it as protective.
Dr. Gedde's last presentation was 'Selective Laser Trabeculoplasty'. Conclusions were that laser trabeculoplasty is a safe and effective method to provide IOP reduction. ALT and SLT appear to be equally effective. SLT offers the theoretical advantage of being repeatable. SLT may be particularly useful in eyes that have undergone prior ALT.
Dr. Don Budenz
Dr. Don Budenz presented 'Clinical Uses and Interpretation of OCT in Glaucoma'. Advantages include rapid acquisition of thousands of A-scans, improved resolution, minimization of motion effect, volume measurements and back-compatibility with Stratus OCT.
He also presented 'Diagnosing Glaucoma Progression with Visual Fields' in which he stated that glaucoma progression is easy to detect, it requires good baseline information, beware of false positive results, confirm suspected progression before changing target pressure, and correlate clinically.
Dr. Budenz then spoke on Trabectome technology, which he states is user-friendly, allows for controlled intraocular surgery, is a minimally invasive out-patient procedure, re-establishes physiological conditions, is associated with low patient risk, is FDA approved, has easy skill transfer and fast patient recovery. He also showed great videos related to the surgery.
Dr. Craig McKeown
Dr. Craig McKeown presented 'Pitfalls and Pearls in Adult Strabismus'. As well, he presented 'Pitfalls and Pearls in Pediatric Ophthalmology'. Pitfalls include difficulty obtaining a history and problems with cooperation. He discussed the 3 periods of development for visual acuity. Also important in his discussion were masquerade syndromes, such as congenital glaucoma masquerading as NLDO. Pearls to differentiate the two include photosensitivity, asymmetry in corneal diameter and corneal clouding in congenital glaucoma. Amblyopia may masquerade as a normal child and retinoblastoma and neurologic disease can masquerade as strabismus.
Dr. McKeown lastly presented cases using titanium T-plates both in a patient with complete 3rd nerve paralysis and a patient with nystagmus and oscillopsia. He showed fascinating pictures of the surgical procedure performed jointly with one of our orbital surgeons.
Dr. Sonia Yoo
Dr. Sonia Yoo presented 'How to Manage Refractive IOL Surprises' where she presented various cases with options for treatments. She polled the audience then revealed her course of treatment. Pearls included: For piggyback IOLs, use a thin, 3 piece lens in the sulcus over an acrylic in the bag IOL. If performing LASIK after IOL, wait at least 3 months if the flap is not created in advance of IOL surgery. When correcting refractive errors after IOL surgery, rule out other causes of ametropia.
Her next talk was about cataract surgery in Fuchs's Dystrophy. Again, cases were presented, the audience was polled and treatment was discussed.
Dr. William Culbertson
Dr. William Culbertson presented 'Managing the Misbehaving Pupil in Cataract Surgery' in which he discussed new instruments and devices to optimize pupil control including pharmacologic agents such as Epi-Shugarcaine, viscoelastics such as Healon V, pupil stretchers such as the Beehler expanders and iris hooks and rings such as the Malyugin Ring.
Dr. Wendy Lee
I presented 'Laser Resurfacing of the Eyelids', discussing various systems useful in reducing fine wrinkles and dark circles on the lids, including Fraxel, Pearl, and Active FX. Pre-procedure evaluation, treatment parameters and post-procedure care was discussed. My next 2 talks were on botulinum toxin and dermal fillers. Injection indications and technique were discussed as well as the various dermal filler products commonly used. An electronic virtual educational (EVE) device was introduced in order for participants to practice their botulinum toxin injections.
Other talks were given by Dr. Carmen Puliafito (Retinal Evaluation of the Preoperative and Postoperative Cataract Surgical Patient and OCT), Dr. Barry Seibel (Phacodynamics, Dual Linear Control, and Chopping Techniques, Refractive Cataract Surgery and Patient Selection; Presbyopia Correcting IOLs and Astigmatism Management, and Medical Product Development), and Dr. Steven Schwartz (Robotic Eye Surgery, Current and Future Treatment for Diabetic Retinopathy, and Current and Future Treatment for AMD).
The meeting was a great success again this year, very entertaining and everybody seemed to enjoy themselves. We look forward to continuing the tradition next year and encourage ophthalmologists from around the world to join us. For more information, log in to bascompalmer.org.