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HIGHLIGHTS
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The future of home vision monitoring has arrived!
and lesions in 06 Ofeyetumors care...
AAO 2021 Introduction Let the Good Times Roll by Sam McCommon
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t wouldn’t be a classic ophthalmology conference without a ceremony-filled and broad-spectrum introductory session. And the American Academy of Ophthalmology’s (AAO 2021) first day did not disappoint — the first session nailed the macrovision, zoom-out view of where the field has been, where it is, and where it’s going.
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Matt’snifesto By Matt Young, CEO of Media MICE
I’m tired of hearing about endless innovations that really only benefit the developed world.
I’m tired of hearing about how ultimately, it’s the patients that we care about.
Where exactly do we care about? There are entire countries, and sometimes continents, that never make it into the commercialization lexicon.
At this AAO annual meeting, as our field discusses eye care at the world’s most prominent venue, bear in mind that much of that care will never end up where it’s needed most.
This must change. Be part of the conversation for the betterment of global eye care. Start just one conversation today, and make a difference in the world.
Great change starts with awareness.
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13 November 2021 | Issue #1
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CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments
>> Cont. from Page 1
Before we get too far, let’s give a brief round of kudos to the AAO’s audiovisual team for some stellar work — the tunes are groovy and the video production top notch. Whoever hired them made a good choice, too. The forward-thinking nature of the whole organization can be seen in just about everything it does, including the quality of its introductory session. Dr. Bruce E. Spivey, CEO of the Academy from 19781992, put it well: “If you’re not doing new things, new programs, you’re going to be behind. Happily, the AAO has never been behind.”
“If you’re not doing new things, new programs, you’re going to be behind. Happily, the AAO has never been behind.” — Dr. Bruce E. Spivey, CEO of the Academy from 1978-1992
He’s right — the AAO has been at the forefront of medical progress since its very inception 125 years ago. Boasting more than 32,000 members, the Academy is a force to be reckoned with. This meeting is a force to be reckoned with as well: With more than 5,800 attendees, it’s the largest ophthalmic conference since AAO 2019. If you’re breathing a sigh of relief seeing that inperson conferences are coming back to life, know that we are, too.
The bird’s eye view To know how to move forward, it’s good to take stock of where one is. That task fell to Dr. Tamara R. Fountain, the outgoing Academy president, who gave us a thought-provoking and adequately broad view of not just ophthalmology, but its place in society at large. One of the first things Dr. Fountain touched on was the Great Resignation — what many call the case of the disappearing American worker. And there’s no beating around the bush here: It’s a big deal, and it represents seismic changes in society. Millions of people have quit and are quitting their jobs.
So, like...why? Dr. Fountain asserts, with much support, that people are seeking deeper meaning than before. We’ve all had a chance to do a bit of soul searching lately, and many non-ophthalmologists came to the conclusion that they weren’t satisfied with their lives or their jobs due to a lack of meaning. That means it’s time for a change.
“The business of medicine can be challenging and grinding in ways we have not seen in our professional lifetimes.” — Dr. Tamara R. Fountain But when ophthalmologists stop to consider what they’re doing, it appears that many remain satisfied with their work. And why shouldn’t they be? After deep reflection, the decision to focus on maintaining and improving vision is a laudable goal by any measure. That doesn’t mean doctors and those in the industry should stop and pat themselves on the back — just that, after deep reflection, eye care really is worth it. And by “it” we mean all the countless hours of labor, learning, communication and
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13 November 2021 | Issue #1
commitment that go into the practice. The goal is there, it’s noble, and we needn’t deviate off course. That doesn’t mean it’s easy — as every ophthalmologist knows, it can be a difficult job. However, as Dr. Fountain pointed out, ophthalmologists consistently rank high on the happiness scale among medical practitioners, and doctors in general rank highly in terms of happiness. Why? The meaning is there. Vision matters. Simple concept, difficult application. But, as she also said, “The business of medicine can be challenging and grinding in ways we have not seen in our professional lifetimes.” It’s true: The rules of the game have changed, and in many ways the difficult setting has gone up. However, with a community-minded spirit and a focus on diversity, equity and inclusion, we can rest assured that the ophthalmic community — spearheaded by the AAO — can and will overcome
these challenges. This year’s official AAO board group photo — masks and all — will one day be a relic of the past, and just a distant memory. I mean, we hope.
So, what’s next for the AAO? One of the biggest things happening right now in the AAO is the intelligent research in sight (IRIS) registry, hosting data from tens of millions of patients and hundreds of millions of patient encounters. It’s the largest registry of its kind in any subspecialty in medicine, and will provide the data doctors need to move forward. “The IRIS data registry may be one of the most important things the Academy has done in decades,” said Dr. David W. Parke II, longtime CEO of the AAO and one of the key players in the industry at large. “It’s a marriage of big data analytics — looking at what’s happening in the real world of practice. It’s really focusing on how well we as ophthalmologists do.”
“The IRIS data registry may be one of the most important things the Academy has done in decades.” — Dr. David W. Parke II, CEO, AAO Education is the pillar of the AAO, and the data gleaned from the IRIS registry will be one of the most valuable tools in history for ophthalmic medicine. Combined with huge improvements in AI, we can expect leaps and bounds in the near future. Tech is accelerating everywhere, of course, but the way it’s accelerating in ophthalmology is especially exciting.
Awards and the Jackson Memorial Lecture The introduction included a number of awards for such exceptional careers that each could fill a book. It would be a shame to share a whole career as a simple bullet point, so we’ll save each for a much-needed deep dive at a later date. For now, we’ll give a much-deserved tip of the hat to the Laureate Award winners from 2020 and 2021. 2020’s award went to Dr. George B. Bartley, with about as storied an ophthalmic career as one could imagine. 2021’s went to Dr. Michael T. Trese, who revolutionized the field of pediatric retinal care — most specifically by confirming that pediatric retinal detachment must be treated entirely differently than similar adult issues. And, to end on a positive note, we’ll briefly address the subject of the 2021 Jackson Memorial Lecture: Advances in infectious eye disease diagnosis and treatment, given by Dr. Russ Van Gelder. His whole lecture deserves far more than the paragraph it gets here, but we’re just thrilled to be talking about new infectious diseases for a change. What a relief! With that, we’ve gone from the extreme zoom-out view to the close-up. The nitty gritty. What we’re all here for. For those visiting in person, enjoy New Orleans. Try to catch a show at Tipitina’s — that’s an insider tip for you. And be sure to enjoy some good ol’ Cajun food.
CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments
difficult to manage the acute onset of neovascular disease that requires timely treatment, and maintaining patient compliance. For intermediate AMD patients, the Notal Vision Monitoring Center services are a fantastic step into the future of remote patient monitoring.
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Digital Health The Future of AMD Patient Care is Here by Sam McCommon
T
he trend towards incorporating digital health in patient care is here to stay — and it can play a vital role in keeping both doctors and patients up to date with many different aspects of a patient’s vision. Crucially, we should note that digital healthcare that includes a home-based monitoring system isn’t here to replace in-person vision care with a specialist. Rather, a remote monitoring program plays a supporting role and adds another tool to the toolbox in patient observation. While the trend towards digital healthcare seemed inevitable, it was greatly accelerated by the pandemic. Now that the medical industry in general is aware of the value of digital healthcare and home monitoring, specialized third-party providers can help clinics seamlessly implement these advances into their practices.
Preventing AMD vision loss with digital healthcare As Dr. Sid Schechet, from Maryland, USA noted, “During the pandemic, I relied
heavily on the Notal Vision Monitoring Center and the ForeseeHome AMD Monitoring Program for patients being followed with intermediate age-related macular degeneration (AMD). I was able to capture conversions in a number of patients who were still asymptomatic, thereby initiating treatment earlier to improve the long-term vision gains.” Patients also felt a sense of security knowing they were getting continuous monitoring from their doctor, so even if they weren’t able to go directly to the clinic they could at least be aware of their status. But in the post-pandemic world, digital healthcare and at-home vision monitoring aren’t going anywhere — and are becoming the rule rather than the exception. Dr. Schechet put it poetically: “Quite literally, remote monitoring extends the doctor’s ability to care for patients between office visits; technology can help us practice better medicine.” It’s quite simple, really: Advanced home monitoring provides better long-term visual outcomes by tracking vision changes between office visits, when it’s
One of the most significant aspects of the ForeseeHome AMD Monitoring Program is it costs nothing for practices to offer the service to their patients. The Notal Vision Monitoring Center does all the legwork getting the program covered by the patient’s insurance, shipping the device, training the patient to use it, and providing continuous patient support and compliance monitoring. When patients perform their daily test, the ForeseeHome device’s artificial intelligence algorithm automatically analyzes and sends the data to the Monitoring Center. Any significant changes in testing, which may indicate a conversion to neovascular AMD, are reviewed by in-house ophthalmologists and an alert is sent to the patient’s doctor so they can determine the best course of action. This constant availability of testing and monitoring plays a vital role in protecting patients from worsening conditions they may not notice on their own. Doctors can also access the secure patient data portal at any time, which provides clinically actionable insights to help guide in-office interactions.
AI assistance, not replacement Remote, algorithm-based home monitoring is already proving itself to be a laudable tool — and it certainly will not replace any in-person clinic care. We’re always in favor of a “why not both?” solution, and the Notal Vision Monitoring Center is the perfect example of that. It’s a win-win scenario for both doctor and patient. We love it when that happens. Kudos to the Notal Vision Monitoring Center for their commitment to improving visual outcomes through digital health — we can’t wait to see what they cook up next. In the meantime, they’ll be helping intermediate AMD patients take control of their condition.
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13 November 2021 | Issue #1
Tumors and Lesions: Oh My! by Brooke Herron
T
he first day of the American Academy of Ophthalmology (AAO 2021) conference kicked off with the always popular “Subspecialty Day.” We were onsite in New Orleans to check out some of these offerings, including the ASORN Nursing Program, which featured sessions on ocular tumors, ocular surface lesions and reconstruction, and more. Below, we cover some of those highlights.
Diagnosis: Tumor Ocular cancers are rare, said Prof. Hakan Demirci, MD, Kellogg Eye Center (Ann Arbor, Michigan, USA). For example, in the U.S. with a population of 350 million people, about 4,000 will develop them. However uncommon, these cancers need to be treated to not only save vision, but to prevent progression as well. Prof. Demirci shared his insights into some of the “more common” cancers that occur in-and-around the eye, including treatment options.
Choroidal nevus
One of the most common ocular cancers is choroidal nevus, said Prof. Demirci. “In simple terms, it is a mole: On the skin, it’s a mole — but in the eye, it’s choroidal nevus,” he explained. He shared that these nevus actually appear as a mole appears on the skin: They are flat or minimally elevated, usually slate grey or melanotic, and show overlying drusen or subretinal fibrosis. Prevalence is higher in Caucasians (4.17.9%) compared with other races.
The good news is that choroidal nevus rarely progresses to malignancy: “One in almost 9,000 will develop cancer,” he continued. Risk factors for malignant choroidal nevus include thickness greater than 2mm, subretinal fluid, symptoms and orange pigment, among others.
Uveal melanoma
“Uveal melanoma is the most common ocular tumor, but even so, it’s rare,” said Prof. Demirci, noting that although melanoma is in the name, this condition is not sun-related.
It occurs in about 5-6 patients per million and is mostly seen in middle age to elderly patients. He shared that this cancer can be asymptomatic or cause visual symptoms. “That’s why I always tell patients, if your vision is getting worse, it’s always a good idea to have an eye examination — and it’s really worth getting a dilated eye examination.” He said that there are two main management options: enucleation or radiotherapy (i.e., plaque and proton beam radiotherapy). The most commonly used primary treatment involves brachytherapy, a type of internal radiation therapy in which seeds that contain radiation are placed on the eye near the tumor. “It’s a very unique treatment for the eye … where you can use this localized radiation,” he said. Outcomes show that brachytherapy produces a local tumor control rate of up to 97% at 5 years. Prof. Demirci also shared details on a new therapy which utilizes virus-like drug conjugates (VDCs). “What it does is it causes the tumor to die — to become necrotic,” he explained.
Choroidal metastasis
When it comes to intraocular tumors, choroidal metastasis is the most common. “Like any cancer in the body, it can spread to anywhere, and they can come to the eye, unfortunately,” said Prof. Demirci, adding that breast and lung cancers are the two types that are most likely to spread to the eye. Treatment options include: external beam radiation, systemic chemotherapy, hormonal therapy, brachytherapy and enucleation. “However, there is another hope for these patients … and that is photodynamic therapy (PDT),” he said. When PDT is used in these patients, it can provide reasonable tumor control in small-to-medium sized metastasis and improve or stabilize visual acuity.
CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments
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Retinoblastoma
This intraocular cancer occurs in children and is very rare, said Prof. Demirci. “Usually it is in one eye, but it can affect both eyes … and about 90% of the patients may have some family history.” Presenting symptoms include leukocoria; strabismus; red, painful eye; poor vision; family history; orbital cellulitis; and vitreous hemorrhage. “The treatment of retinoblastoma is very individualized: Is it one of both eyes? What’s the size of it? Where’s it located? Depending on that, we can treat this patient,” he said. “It’s a very multidisciplinary approach because it’s not only the eye doctor.”
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Surgical approaches to ocular surface lesions During the presentation from Prof. Jeffrey Ma, MD, UC Davis Eye Center (California, USA), attendees were treated to some fascinating surgical videos on benign ocular surface lesions and reconstruction.
His surgical objective was to remove adhesions to the cornea, palpebral conjunctiva and eyelids; reconstruct the fornices; preserve the cornea and lacrimal duct; improve extraocular motility and vision; and prevent future recurrence of adhesions. (Editor’s note: Unfortunately, this presentation isn’t available on demand — but take our word for it, the surgical video was impressive.) “At one month post-operatively, the adhesions are gone. The cornea is still kind of hazy and I expected that because we couldn’t remove all that scar tissue. There is some granulation tissue that is starting to form again … and I did end up taking her back to resect some more of that tissue. “Interestingly, if you look closely in the nasal part of her iris, she has an iridodialysis there. There’s an area where the iris has torn away from its roots and basically, she has a second pupil — this was a result of her initial firework injury,” said Prof. Ma. At 8 months post-operatively, the patient’s corneal scarring continued to regress. “It’s looking much better and she says that her vision is better, she’s not having any pain. What she is complaining about is when she looks at lights, she sees a lot of glare — and that is an unintended consequence of getting rid of all the corneal scarring which has allowed light to pass through this iris defect,” he said. “This is something that we’ll probably have to address in the future.”
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His first case study was that of an 18-year-old, otherwise healthy, female who had sustained a firework injury causing a ruptured globe one year prior. When the patient presented, there was a lot of scarring and adhesions (indeed, the image he shared caused an audible gasp from the audience). These adhesions spanned from the under surface of the eyelids, to the nasal aspect of the fornice, and all the way to the cornea.
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