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C A K E A N D P I E M A G A Z I N E S ’ D A I LY C O N G R E S S N E W S O N T H E A N T E R I O R A N D P O S T E R I O R S E G M E N T S

HIGHLIGHTS patients first 04 Putting can lead to a jackpot post-cataract surgery outcomes.

06 Ophthalmologists discussed how technological advancements can help drive the road to perfection! share tips in 09 Experts managing unhappy patients.

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Matt Young CEO & Publisher

Robert Anderson Media Director

Hannah Nguyen Production & Circulation Manager

Gloria D. Gamat Chief Editor

Brooke Herron Editor International Business Development

Ruchi Mahajan Ranga Brandon Winkeler

Recognizing and Overcoming Burnout by Brooke Herron

R

unning an ophthalmic practice in a normal year can be stressful — and we can all agree that 2020 has not been a normal year.

The COVID-19 pandemic has caused massive changes in ophthalmic practice. Throughout the year, clinics have had to manage closures, restrictions, added safety measures — as well as ensure patients continued to be monitored and treated.

a definition of burnout from Dr. Michael Johns, which says “burnout is a consequence of an adverse work environment, period.” Cont. on Page 3 >>

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We all have stress — and likely have experienced burnout, particularly this year. Therefore, an AAOE plenary session called Keep the Fire Lit: Strategies for Preventing Burnout was held on the last day of AAO 2020 Virtual. During the session, panelists Robert Melendez MD, MBA, and Marilyn Ponder DBA, discussed common stressors in daily practice and how to create a workplace with improved team dynamics and reduced stress.

What is burnout? Opening the session, Dr. Ponder borrowed

Now everyone wants a Virtual Vegas Vest! That’s ok. Brandon, Matt and everyone at Team Media MICE wish you all the vest as 2020 comes to an end, vinylly!


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16 Nov 2020 | Issue #4

Chec OCT k Diana resu lts.

OZURDEX® has multiple modes of action,1–3 a low treatment burden4–7 and a manageable safety profile.6–8

TRY DIFFERENT LETTERS IN YOUR PRESCRIPTION FOR DME

DME, diabetic macular edema; OCT, optical coherence tomography. 1. Nehmé A and Edelman J. Invest Ophthalmol Vis Sci 2008;49(5):2030–2038. 2. Holekamp N. The role of corticosteroid implants in DME. Available at: http://retinatoday.com/2015/04/ the-role-of-corticosteroid-implants-in-dme. Accessed March 2020. 3. Campochiario PA et al. Am J Ophthalmol 2016;168:13–23. 4. Malclès A et al. Retina 2017;37(4):753–760. 5. Matonti F et al. Eur J Ophthamol 2016;26(5):454–459. 6. Aknin I and Melki L. Ophthalmolgica 2016;235:187–188. 7. Allergan. OZURDEX®. Summary of Product Characteristics. October 2019. 8. Boyer SB et al. Ophthalmology 2014;121(10):1904–1914.

INDICATIONS & USAGE: OZURDEX® contains a corticosteroid indicated for the treatment of macular edema following branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO), for the treatment of non-infectious uveitis affecting the posterior segment of the eye, and for the treatment of patients with visual impairment due to diabetic macular edema (DME) who are pseudophakic or who are considered insufficiently responsive to, or unsuitable for non-corticosteroid therapy. DOSAGE & ADMINISTRATION: For ophthalmic intravitreal injection only. The intravitreal injection procedure should be carried out under controlled aseptic conditions. Following the intravitreal injection, patients should be monitored for elevation in intraocular pressure and for endophthalmitis. DOSAGE FORMS & STRENGTHS: Intravitreal implant containing dexamethasone 0.7 mg in the NOVADUR™ solid polymer

drug delivery system. CONTRAINDICATIONS: Ocular or periocular infections. Advanced glaucoma. Aphakic eyes with ruptured posterior lens capsule. Eyes with ACIOL, iris or transscleral fixated IOLs and rupture of the posterior lens capsule. Hypersensitivity. WARNINGS AND PRECAUTIONS: Intravitreal injections have been associated with endophthalmitis, eye inflammation, increased intraocular pressure, retinal detachments, and implant migration into the anterior chamber. Patients should be monitored following the injection. Patients who has a tear in the posterior lens capsule (e.g., due to cataract surgery), or who had an iris opening to the vitreous cavity (e.g., due to iridectomy) are at risk of implant migration into the anterior chamber. Use of corticosteroids may produce posterior subcapsular cataracts, increased intraocular pressure, glaucoma, and may enhance establishment of secondary ocular infections due to bacteria, fungi,

or virus. Corticosteroids should be used cautiously in patients with a history of ocular herpes simplex. ADVERSE REACTIONS: In controlled studies, the most common adverse reactions reported by 20–70% of patients were cataract, increased intraocular pressure and conjunctival haemorrhage. Licenses may vary by country, please consult your local Summary of Product Characteristics. Adverse events should be reported to your Ministry of Health and local Allergan office. Date of preparation: March 2020 INT-OZU-2050060 OZURDEX® is not licensed for use in DME in China.


CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

>> Cont. from Page 1

Burnout is a syndrome that results from chronic stress at work and has several consequences to workers’ well-being and overall health, she continued, adding that it can also lead to physical consequences like diabetes and heart disease, as well as insomnia and depressive symptoms. However, it can also have professional consequences, including job dissatisfaction, absenteeism and poor performance. “Burnout is linked to mental health — and a 2018 survey found that 46% of ophthalmologists felt burnout, depressed or both,” said Dr. Ponder, adding that these issues can be further exacerbated by the pandemic. “Burnout is a threat for us, our patients and our organizations,” she continued. Symptoms of burnout include: exhaustion, cynicism, low sense of personal accomplishment, depersonalization, poor judgment and guilt.

So, who is the most burned out? According to a MedScape survey, women physicians are more likely to experience burnout (48%) compared with men (37%). Young parents are also more likely to experience burnout, as well as young physicians under the age of 55. And of all the specialties, 30% of ophthalmologists report burnout — and while that’s not the highest number, Dr. Melendez says it’s still way too high. Dr. Melendez says if employees are exhibiting symptoms of burnout, there’s one important question to ask (if the problem is professional): “What resources do you need to be successful?” He says this question shows empathy, and that most people might respond with something simple. “You need to pinpoint the problem. Often times people will beat around the bush and not be specific, so you have to ask them ‘what specifically is frustrating you?’” “Burnout is something that creeps up on you,” added Dr. Ponder. “Genuine burnout leads to an inability to successfully function on a personal, social and professional level. It steals

hope and squashes motivation… and burnout is a leading cause of job dissatisfaction.”

What contributes to burnout? Dr. Melendez shared a list compiled from a MedScape survey listing numerous reasons for burnout. Among the top five were: too many bureaucratic tasks (55%); spending too many hours at work (33%); lack of respect from administrators, employers, colleagues or staff (32%); increasing computerization of practice (30%); and insufficient compensation or reimbursement (29%). “The most important organizational factors that may lead to burnout are working too many hours and doing too many tasks,” he said. “And we’ve all noticed with COVID, that we’re having to do more with fewer staff, fewer resources...a lot of us are doing two or three jobs, but that’s only going to last for a certain period of time.” He says leaders should communicate with their teams that let them know that this is not going to last forever, and they will get through it. “For me personally, poor quality of communication at work is key to leading to burnout,” shared Dr. Melendez. And overall, the importance of communication at all levels was stressed as an important factor in avoiding burnout.

How can you reignite that fire? “We want to focus on engagement — which is typically the opposite of burnout. Engagement is a state of enthusiasm, characterized by belonging, pride and loyalty. This fosters a mutually committed relationship between physicians and organizations,” said Dr. Melendez. Part of this is fostering emotional intelligence (EI), which is the ability to recognize, understand and manage your own emotions; and to recognize, understand and influence the emotions of others. “I find the application of EI in the workplace to be very practical, not just theoretical,” said Dr. Ponder. “For leaders, having emotional intelligence is essential.”

There are five elements to the theory of EI, according to Dr. Ponder. These include self awareness, self regulation, motivation, empathy and social skills. So, how do physicians cope with burnout? Dr. Melendez presented another MedScape survey on this topic. These were the top coping mechanisms: isolation from others (45%); exercising (45%); talking with family and friends (42%); sleeping (40%); eating junk food (33%); and playing or listening to music (32%). Another way to cope with burnout? Dr. Melendez suggests getting back to your “why.” That is, “why you do what you do.” He then showed a video of a child getting glasses and seeing for the first time — and that smile is the “why” for many ophthalmologists. “When you’re operating on your ’why’ everyday, it’s hard to be thrown off your game.” Dr. Ponder then suggested some things to help alleviate burnout. “Start with the things you have control over. Be cautious not to take on more than you can reasonably accomplish. It’s essential that you delegate tasks when appropriate — it moves stuff off of your plate and it helps the other grow.” She also highlighted the importance of exercise and eating well, and getting enough sleep. “Take responsibility for your actions, rather than placing blame. Lead when the opportunity presents, and forgive others,” shared Dr. Ponder. “I would also add that burnout can be avoided if we work to take care of ourselves and create work environments that encourage open communication and promote work-life balance,” concluded Dr. Ponder.

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16 Nov 2020 | Issue #4

Hitting the Jackpot with Refractive Cataract Surgery

by Olawale Salami

Patients are continually demanding a better quality of life with the best possible vision after cataract surgery, and satisfying this demand was the theme of presentations and discussions during Symposium 48 on Day 3 (Sunday, November 15) of the AAO 2020 Virtual. Below are some of the highlights...

My patients are falling… but not for me “By offering refractive cataract surgery, we can help prevent these falls and reduce morbidity and mortality in our patients,” said Dr. Daniel Chang of the Empire Eye and Laser Centre (California, USA). In routine cataract surgery, we start by extracting cataracts, and then we use glasses to correct astigmatism and presbyopia, noted Dr. Chang. “But in refractive cataract surgery, we try to do all these at the same time, surgically. Therefore, we should ask ourselves, what is the added advantage... does refractive cataract surgery offer convenience for the patient,” he asked the audience. “When we think about the option of refractive surgery in each patient, we try to weigh the risks and benefits,” shared Dr. Chang. Fundamentally, presbyopia treatment for each patient is not optional and will be treated either surgically or with glasses. “We consider convenience, patient satisfaction, safety, and quality of life from the surgical perspective, but we worry about the quality of vision, cost, night-vision symptoms and operating time,” he explained. On the other hand, glasses, benefits include noninvasiveness, adjustability, and fashion, but risks include limited peripheral vision, depth perception, nose/ear irritation and edge contrast sensitivity, Dr. Chang elaborated.

The rising cost of falls According to Dr. Chang, the loss of edge contrast sensitivity and depth perception increases the risk of falls in patients using bifocal glasses. In the elderly, this is a particularly essential data that suggests that over a third of falls in the elderly are attributed to depth perception problems with bifocal glasses. These multifocal glasses-related falls result in over 250,000 hospitalizations and over 10,000 deaths. Those patients who are not injured develop post-fall anxiety syndrome. Overall, the impact of multifocal glasses-related falls in the United States is about 10 Billion USD every year. Modeling has shown that if we adopted universal surgical correction of presbyopia in all patients, these would result in annual cost savings of about 14 Billion USD.

The unhappy patient “Inevitably, we may still end up with some unhappy patients. For these, it is important to assess for possible occult

macular pathology,” said Dr. Russel Swan, adjunct assistant professor at the University of Utah (USA). In the world of refractive cataract surgery, there are so many happy patients, according to Dr. Swan. However, occasionally, we find a patient who has some degree of frustration, and we want to find a way to turn this frown into a smile, he emphasized. “Identifying patients who will be poor candidates for refractive cataract surgery goes a long way in reducing patient frustration,” explained Dr. Swan. There are many reasons for this, like irregular astigmatism or higherorder corneal aberrations or occult macular pathology. Preoperative testing should include topography, ACT, tear film analysis, aberrometry, K’s, and lens analysis. “If we identify irregular astigmatism with a curable cause, such as Salzmann’s nodular degeneration, we can improve their higherorder corneal aberrations by repairing this or performing pterygium repair before cataract surgery,” added Dr. Swan. Preoperatively, according to Dr. Swan, it’s also necessary to explain to patients that lenses have clarity and flexibility characteristics. Therefore, the limitations of glasses after cataract surgery must be well explained, vis-à-vis patients’ lifestyles to understand their postoperative expectations. “Intraoperatively, some factors could be considered to improve patient satisfaction. These include the precise capsulotomy technique and the use of intraoperative aberrometry,’ Dr. Swan explained. “Overall, by far, the most common cause of low patient satisfaction is an uncorrected refractive error. Secondly, ocular surface diseases, like dry eyes, represent important causes of low patient satisfaction, which can be easily treated with medications and environmental modifications to maximize patient comfort,” he added.


CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

Pearls For Complicated Phaco Cases by Hazlin Hassan

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n this dynamic rapid-fire session on the final day of the American Academy of Ophthalmology annual meeting (AAO 2020 Virtual) on Sunday (November 15), several experts presented their top five pearls for managing complicated cataract cases or situations. Dr. Jessica Ciralsky’s top five pearls for dealing with phaco with uveitis are: identify the underlying etiology, plan ahead for surgery, control the iris, choose your intraocular lens (or lack of) wisely, and actively manage corticosteroids. The associate professor from Weill Cornell Ophthalmology (USA), said one must first know the cause of uveitis. “Rule out infectious uveitis and control the underlying problem,” she said. There should be a period of quiescence before the surgery, of at least three months although six months is often preferable. When planning for the surgery, other pathologies should also be ruled out. Dr. Ciralsky advised having a surgical plan and a back-up plan, adequate anesthetic, and a contingency tray ready with iris hooks, rings, capsular tension ring, and capsule scissors. In choosing an IOL, she prefers to use acrylic lenses, and avoids silicone and multifocals. Oral steroids are often dosed at 1 mg/ kg typically starting 3 days prior, and tapered over one month depending on severity or response. She added that she was also “aggressive” with postoperative topical steroids, tapered over two months, topical NSAID for a few months and topical mydriatic for two weeks post-op. Subtenon’s or intraocular steroids may be considered if oral steroids are contraindicated.

IV anti-VEGF drugs and steroids can be combined with cataract surgery and are effective if diabetic macular edema (DME) is still present, he added. Finally, managing CME post-cataract surgery initially consists of topical NSAIDs, and can be combined with steroids. Douglas J. Rhee MD, professor and chair, Department of Ophthalmology and Visual Science, University Hospitals Eye Institute, Case Western Reserve University School of Medicine (USA), presented his pearls on how to manage phaco with glaucoma.

Professor Rudy Nuijts MD, president of the European Society of Cataract and Refractive Surgery (ESCRS), shared his pearls on preventing and managing cystoid macular edema (CME). In a European multicenter trial of the prevention of CME after cataract surgery in nondiabetics, 914 patients were randomized to three treatment groups: bromfenac, dexamethasone, and a combination of the two. The incidence of CME within 12 weeks was highest in the dexamethasone group at 8.5%, and 41.% for bromfenac. The odds of developing CME were lowest in the combination group at 2.3%. “Patients treated with a combination of topical bromfenac and dexamethasone had a lower risk for developing clinically significant macular oedema (CSME) after cataract surgery than patients treated with a single drug,” he said. Another randomized controlled European multicenter trial on the prevention of CME after cataract surgery in diabetics involving 213 patients found that a subconjunctival Triamcinolone Acetonide (TA) injection effectively prevents the development of CME. “In diabetic patients without diabetic retinopathy, we treat as in routine cataract surgery: a combination of NSAIDs and steroids,” he advised.

Indications on when to add glaucoma surgery versus phaco alone include uncontrolled intraocular pressure, or when IOP is controlled but requires three or more medications, a high risk for IOP spike for example pseudoexfoliation, or when there is a high risk for loss of central fixation. He recommends using iris hooks or Malyugin rings. “I have rarely regretted using iris hooks or the Malyugin ring. I have nearly always regretted not using iris hooks or the Malyugin ring when I thought it might be helpful,” he said. With minimally invasive glaucoma surgery (MIGS), there is no change in surgically-induced astigmatism if using the main cataract wound or paracentesis for the MIGS procedure. With trabeculectomy and tube shunts, there can be surgically-induced astigmatism, and hyperopic shift. “Avoid multifocal IOLs in patients with glaucoma,” he suggested. This is because multifocal IOLs degrade contrast sensitivity. Glaucoma also degrades contrast sensitivity. Even in early stage glaucoma, it is not assured that the patient will not progress. Finally, Dr. Rhee said that topical NSAIDs must be used if the patient is on a prostaglandin analogue (PGA) as topical PGA use can increase the risk of post-op CME. “Anecdotally, post-operative topical NSAID use can decrease the rate of postoperative CME,” he said.

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16 Nov 2020 | Issue #4

Technological Advancements in Ophthalmology by Elisa DeMartino

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he last day’s afternoon session of AAO 2020 Virtual titled 20/20 in Focus: How Technology WIll Bring Us Closer to Perfection was a wonderful hodgepodge review of technological advancements in ophthalmology over the last 10 years. With each presenter packing as much information as possible into only three minutes of allotted presentation time, it felt somewhat akin to new technology speed dating. Unlike many of the technology focused meetings during this weekend’s conference this talk was not in any way corona related. “This title was chosen before COVID,” discussion leader Dr. Jesse Berry, assistant director of Ocular Oncology at the USC Gayle and Edward Roski Eye Institute and Children’s Hospital Los Angeles, explained, “otherwise it might have been ‘How technology will help us survive in 2020.’” Because the virtual meeting was co-sponsored by the Young Ophthalmologists Committee, speakers focused on information that might benefit a physician who is still in the early years of their career.

Medical innovations in ophthalmology Professor Jodhbir Mehta of the Singapore National Eye Centre (SNEC) presented first with an eye-opening demonstration about trends and developments in corneal transplant procedures. He explained how EK has overtaken PK as the most popular technique and that the future of conceal transplants lies in selective cell therapy. Next, Dr. Raymond Douglas, director of Kellogg’s Thyroid Eye Disease Clinic (USA), broached the topic of proptosis in thyroid eye disease. In particular he evidenced the use of the medication Teprotumumab as an effective treatment without any serious adverse side effects according to case studies.

Dr. Anne Coleman, director, UCLA Mobile Eye Clinic (USA), followed with her short lecture on why injectable and sustained release drugs are superior to topical eye drop medication in glaucoma management. She elaborated that it is a lower cost option, it ensures that patients won’t avoid or forget their medication regimes, and it circumvents ocular surface disease associated with long-term exposure to medications. During this rapidfire discussion the spotlight also fell on Dr. Martine Jager (professor of ophthalmology, Universiteit Leiden, The Netherlands), Dr. Audina Berrocal (professor of clinical ophthalmology, University of Miami Health System, Florida, USA), and Dr. Marcus Ang (Singapore National Eye Centre) who described technological developments in minimally invasive precision prognostics for melanoma and retinoblastoma, gene therapy for inherited retinal disease, and myopia imaging techniques, respectively.

Modern considerations The next four speakers tackled subjects that, while often trending nowadays, are not frequently discussed in the specific context of ophthalmology. Dr. Thomas Lee (associate professor of clinical ophthalmology and director of the Vision Center Children’s Hospital Los Angeles (CHLA), California, USA), opened his segment with some words of advice. “As you get on in your years you’ll find that it’s very easy to stay in your comfort zone; the purpose of this talk is to make sure you continually push yourself out of that throughout your career.” This mindset is how he created a program to treat premature retinopathy

in Armenian youth by using telemedicine to instruct ophthalmologists there about treatment and surgical procedures. Ophthalmologist-in-Chief of Wills Eye Hospital Dr. Julia Haller, proceeded to inspire us with words of advice but also of warning for women in medicine. Telemedicine and e-care offer flexibility for women to maintain a busy clinical career, and remote mentoring opportunities for females present increasing opportunities for guidance; despite this, “in 2020 women have lost ground on previous leadership gains despite the technology that allows us to move work home and to juggle our time schedules.” Dr. Michael Abramoff (Robert C. Watzke professor of ophthalmology and visual sciences at the Roy J. and Lucille A. Carver College of Medicine at the University of Iowa, USA), stepped up to give a rundown on the ethical principles of autonomous AI and how it can be applied to better the lives of patients, meanwhile cautioning that assistive AI can sometimes result in worsened outcomes if not rigorously validated. Finally, Dr. Michael Chiang (associate director of the OHSU Casey Eye Institute, USA) demonstrated how big data has set the stage for knowledge discovery in ophthalmology, particularly in the development of the AAO’s IRIS Registry in 2014. He suggested that challenges to data collection might include accurate and quick capturing of data as well as harmonization of documentation standards across providers. The discussion closed with an inspiring Q&A, led by Dr. Arvind Saini (ophthalmology specialist in Escondido, CA, USA), focusing on ways young ophthalmologists might further their career. Panelists posed career oriented questions to one another and contributed some words of wisdom learned throughout their many years of experience.


CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

AAO 2020 Exhibitor Showcase Reporting on the newest products and launches from ophthalmology’s leading companies by Brooke Herron

Calling all Cataract Surgeons Cataract surgeons take note: The Cassini Ambient has arrived. Showcased at the Cassini Technologies AAO 2020 Virtual exhibition, this device is described in their featured video as the “confidence game-changer that has transformed practices.” The Cassini assesses ocular surface stability, measures the posterior cornea, and detects corneal irregularities with LED topography. It boasts comfortable illumination, FLACS connectivity, and automated transfer of patient data, corneal information and iris registration — creating what Cassini calls “a formidable connection.” The Cassini Ambient is backed by surgeon experience, too. It’s been described as a better tool for toric IOL planning — allowing surgeons to offer premium IOLs with more confidence; while another shares that its central corneal measurements are superior to others in cases of high irregularity. For more information, visit https:// cassini-technologies.com.

Nasal Spray for DED

Shared Vision: Quantel Medical and Ellex Two become one: On July 1, 2020, Ellex joined Quantel Medical. Now, that these two innovative companies are under one roof, they are united by the same objective: To develop cuttingedge technologies for the diagnosis and treatment of dry eye and the leading causes of blindness worldwide (i.e. cataract, glaucoma, age-related macular degeneration and diabetic retinopathy). As part of the Lumbird Medical Group, the company has a presence in more than 110 countries, offering laser systems from their SLT portfolio like Tango™, Tango Reflex and Optimus Fusion. Attendees can also discover the company’s dry eye diagnostics (LacryDiag, an ocular surface analyzer) and treatments (LacryStim I.P.L. treatment system, which is currently not available in the U.S.). For more details on Quantel Medical/Ellex or for more on their products, visit www. quantel-medical.com.

“Oyster Point Pharma is a clinical biopharmaceutical company focused on the discovery, development and commercialization of first-in-class therapies to treat ocular surface disease,” said Jeff Nau, company president and CEO.

free, aqueous nasal spray; its novel mechanism of action activates the trigeminal parasympathetic pathway to stimulate natural tear film production.

The company’s lead product candidate — OC-O1 — is underdevelopment to treat the symptoms of dry eye disease. Using a highly selective nicotinic acetylcholine receptor (nAChR) agonist, OC-O1 is administered as a preservative-

OC-O1 has completed phase 3 trials and will submit for its NDA in Q4 2020. Visit https:// oysterpointrx.com/ for more information.

Optopol Opens US Office, Showcases PTS 2000 Over at the Optopol booth, attendees are welcomed by Bob Padula, president of Optopol USA — the U.S.-based subsidiary of Optopol Technology which opened in January 2020. “Our featured [product] is the Optopol PTS 2000, our top-of-the-line projection perimeter with every option you could imagine,” said Padula, adding that it also costs US$10,000 less than any other similar option. “We also do an HFA import for those who are thinking of upgrading their HFA. You can take all of your data, all of your patient clinical information and export it into the Optopol unit — so, when you start using it, all your old patients and tests are there, ready to go,” he continued. He also highlighted the REVA NX 130 OCT, which is one of the topselling OCTs in the world. The REVA is currently undergoing FDA approval for use in the United States. For more information on any of these devices, check out Optopol USA’s brand new website: www.optopolusa. com.

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16 Nov 2020 | Issue #4

Eye on Intraocular Pressure

When Administering OZURDEX by Hazlin Hassan

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he OZURDEX (Allergan, Dublin, Ireland) dexamethasone intravitreal implant is a corticosteroid approved for the treatment of diabetic macular edema (DME), macular edema following retinal vein occlusion (RVO),and noninfectious posterior segment uveitis. While it has minimal side effects, intraocular pressure (IOP) elevation is the most common, but cases generally do not require surgical intervention. In the industry showcase on the last day of AAO 2020 Virtual presented by Allergan, an AbbVie Company, the use of OZURDEX was discussed, covering efficacy, post-administration management and monitoring techniques. OZURDEX is a tiny implant that slowly releases medication over time, to help reduce inflammation in the retina without monthly injections. It will dissolve over months and will not need to be removed. It is injected directly into the back of the eye. In clinical studies, OZURDEX improved vision in patients without the need for monthly injections. “OZURDEX lasts longer than anti-VEGFs in terms of treating, for example, DME,” said

Jeremy Wolfe, MD, partner at Associated Retinal Consultants (Michigan, USA), and consultant for Allergan.

vitreoretinal surgeon at Associated Retina Consultants and consultant for Allergan.

With intravitreal injections, there is a possibility of an increase in eye pressure that generally returns to where it started.

In the MEAD study which comprised two multicenter phase 3 clinical trials, the OZURDEX implant was shown to improve best corrected visual acuity at 3 years in eyes with DME.

Patients who have been administered the OZURDEX intravitreal injection should be monitored regularly for elevation in intraocular pressure (IOP). However Dr. Wolfe pointed out that an elevated IOP does not necessarily equate to glaucoma. OZURDEX is contraindicated in patients with glaucoma. According to studies, IOP elevations are most likely to occur early in treatment. Fifteen percent of patients who experienced IOP, reported it after their first OZURDEX injection. “Of those who are going to have a pressure response, the huge majority of them will happen within the first three treatment cycles,” said Dr. Wolfe. For DME patients who were given OZURDEX, the peak mean IOP was often 45 or 90 days after the injection, while for patients with macular edema following RVO, it was 60 days. For patients with noninfectious posterior segment uveitis, it was 56 days. The increase in mean IOP was seen with each treatment cycle and the mean IOP generally returned to baseline between treatment cycles (at the end of the sixmonth period). “This is typically what we see in the clinic,” said Dr. Rahul Reddy,

Patients were randomized to study treatment with 0.7 mg and 0.35 mg implants of OZURDEX or sham treatment, and followed for 3 years. BCVA improved by at least 15 letters or more in 22.2% of patients with the 0.7 mg and 18.4% of patients with the 0.35 mg implant compared to 12% of patients receiving sham treatment. “The really significant thing which is different from past steroids is that the incidence of surgery for pressure is incredibly low,” noted Dr. Wolfe. “Safety and predictability are important reasons to propel us forward,” he added. The incidence of elevated IOP requiring surgery was 0.3% in the MEAD study, 0.7% for the multicenter, masked, shamcontrolled six-month GENEVA study involving patients with macular edema following RVO, and 1.3% for patients with noninfectious posterior segment uveitis in the multicenter, masked, randomized 26-week HURON study. IOP checks should be scheduled every six to eight weeks, and can be conducted by technicians. Drive-through or parking lot IOP checks may be considered during the COVID-19 pandemic to reduce the risk of possible exposure.


CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

l’s Dr. Liz Yeu’s and Dr. John Berdah

Tips to Manage Unhappy Patients by Sam McCommon

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ew things are more important to the well-being of a doctor’s career than keeping their patients happy. This is perhaps more true than ever in the age of social media, when an unhappy patient can loudly vent their frustration to strangers — and a doctor’s potential future patients. It’s almost axiomatic that bad news spreads faster than good news, and that holds true when it comes to business reviews as well. So, keeping patients happy is a crucial part of medicine. That much is clear. But what do you do when you have an unhappy ophthalmic patient? Dr. Elizabeth Yeu and Dr. John Berdahl hosted a valuable session on the last day of AAO 2020 Virtual conference. In the course of their discussion, they addressed many forms of patient needs, approaches to handling unhappy patients, and preventative measures. This was one of those excellent allrounder discussions that physicians could turn to again and again.

Listen early, listen often One of the first questions addressed was fairly simple: How frequent is it that a patient’s complaint comes from a legitimate problem rather than a difficult personality? Dr. Berdahl estimated that 95% of patient complaints are legitimate, whether they come from a medical problem or are related to customer service. He noted that it’s easy to blame the patient rather than acknowledging the problem — that’s simply part of human nature, after all. Saying that a patient simply is being difficult is an exclusionary diagnosis of its own,

and such a dismissive approach to a complaint can lead to significant problems for a clinic. Doctors should pay close attention to their patient’s complaints, and at the very least take them seriously. Dr. Yeu noted that complaining patients instantly become VIPs at her practice — it’s best to address the squeaky wheel right away. Doctors should actively seek out and identify complaints. It may even be valuable to give patients a forum to discuss their problems, whether online or via a form. Dr. Berdahl indicated that the majority of patient complaints post-ophthalmic surgery are either from refractive problems or from dry eye disease. Anticipating common problems like these can help doctors develop their own playbook. As Dr. Berdahl poetically put it, “People don’t care what you know until they know that you care.” Simply showing you care is the most important step in doctorpatient relations.

Managing patient expectations A common problem discussed by Dr. Yeu and Dr. Berdahl was patients’ IOL experiences not necessarily meeting their expectations.

Fortunately, IOLs have come a long way even over the last several years. Mixing and matching bifocal lenses, trifocals, and new extended depth-of-focus (EDoF) IOLs mean lower patient complaint rates than ever before. But some patients will still struggle with their new IOLs with problems like dysphotopsia. Dr. Yeu said she tells her patients there’s roughly a one in thirty chance they’ll need to undergo a lens exchange if the first lens they’re fitted with doesn’t work out. Dr. Berdahl had an interesting analogy: If you think about looking at your nose, it can be irritating. We are so used to it we don’t even notice. I extend my apologies to readers who will now spend time looking at their nose. Many patients simply aren’t used to an IOL’s difference to their own eye. Sadly, an IOL will never be as good as our natural lenses at age 20 — but the fact they exist at all is amazing itself. One suggestion Dr. Berdahl gave was this: show patients the difference between using their new IOL versus no IOL. Patients will quickly see what a radical difference the IOL makes versus, well, nothing, and will likely grow to appreciate what the lens does rather than what it doesn’t do. It’s a simple bit of psychology, but hey — it’s honest, and it keeps patients happy. And at the end of the day, ensuring patient satisfaction is a large part of a physician’s job.

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16 Nov 2020 | Issue #4

Bright Lights, Virtual Nights

many arenas … we didn’t know they were gifted actors, videographers, directors and red carpet correspondents as well.

by Brooke Herron

O

ne thing we love about attending these annual meetings is not only the abundant scientific knowledge, but also the camaraderie we develop with each other over happy hours, social events, and other industry-sponsored get-togethers. These casual events allow us to take a break from the rigors of medicine, and simply enjoy — and celebrate — each other’s company. Thankfully, even though we’ve had to attend AAO 2020 virtually this year, there has still been

opportunities to decompress, maybe even with a few laughs. One such event occurred just before AAO Virtual 2020: The 6th Annual Alcon Retina Film Festival Virtual, which showcases the best surgical videos and techniques from surgeons around the world — and the competition was fierce. The Alcon-sponsored program started off with all the fanfare expected from a television award show — and while we know ophthalmologists are talented in

Moderated by Dr. Donald D’Amico, the Festival featured video submissions from the panel including Dr. John Kitchens with a video on Crazy Macular Fold Repair; Dr. Timothy Murray with Two Tumors; and Dr. Maria Berrocal with Tractional Retinal Detachment — 27g. Some of the guest presenters included Dr. Thanos Papakostas with TRD Repair Hybrid; Dr. Eric Nudleman with Retinal Incarceration; Dr. Caroline Baumal with Retinoschisis RRD; Dr. John Miller with Telesurgery over 5G; and Dr. Alan Franklin with NGENUITY Color Channels. And although we can’t list all of the nominees here, you can view with award-worthy surgical videos on demand, anytime (kind of like Netflix for ophthalmologists). Of course, every award show must have its winner and Dr. Christina Weng took home that distinction with her presentation on Autologous Retinal Transplant for Macular Hole. So, watch out Hollywood, the stars of ophthalmology are hot on your tail!

Emily and David provide comic relief and entertainment as the hosts of the Retina Film Festival. [Image provided by Edelman]

Moderator Dr. D’Amico is joined by the panel Drs. Berrocal, Kitchens and Murray. [Image provided by Edelman]

Presenting the Film Festival panel. [Image provided by Edelman]

Dr. D’Amico is joined by Film Festival Winner Dr. Weng. [Image provided by Edelman]


CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

s e r o l p x E m Symposiu e k a M o t s y a W w Ne Clinics More

and Efficient T

his year has presented numerous challenges to ophthalmologists and clinicians alike as they have been forced to alter many of their working practices. The disruptions have included mandatory telehealth implementation, social distancing and personal protective equipment, the list goes on and on. Now more than ever, proper and efficient clinic management is of the utmost importance. That was the crux of Boost Physician Efficiencies: Creating a Lean Culture With Technology, a symposium organized on the sidelines of day three of the annual meeting of the American Academy of Ophthalmology (AAO 2020 Virtual). An in-depth dive into how ophthalmology clinics can maximize their efficiency and improve patient outcomes, the symposium was chaired predicated on the Lean philosophy of workplace management. This is described as a philosophy that ensures businesses that holistically apply lean principles to the way it plans, prioritizes, manages, and measures work.

Lean, mean, recording keeping machine The purpose of applying the Lean principle is to improve patient outcomes as much as to improve corporate efficiency. According to the senior instructor of the symposium,

Aneesh Suneja, president and founder of FlowOne Lean Consulting LLC (Wisconsin, USA), placing the patient at the center of a high-performing team using Lean techniques, physicians and their support teams can become more coordinated and efficient, reduce physician time spent on the electronic medical records (EMR) during the patient encounter, communicate information more effectively and improve the overall patient and provider experiences. Part of this involves the usage of virtual scribes, who can greatly reduce the ophthalmologist’s time spent on EMR and its burden on staff. The objective of the symposium was to explain how a physician can increase efficiency with three strategies, including remote scribing, patient flow tracking and team communication practices such as micro-huddles and provider/technician in-room overlap. Mr. Suneja used detailed flow charts to showcase how time wasting could be mitigated, and valued time activities like face to face consultations could be maximized. The ‘Five S’ format was crucial, which is to sort (identify necessary items), set in order, shine (clean), standardize and sustain.

S, S, S, S, S Using the ‘Five S’ system combined with an awareness of one’s colleagues

by Andrew Sweeney

and infrastructural capabilities can allow any clinic to become more efficient than ever, according to Mr. Suneja. A key part of this process is to minimize patient footprints (i.e. keeping facilities required by patients close to each other). A good example would be keeping imaging facilities close to one another, rather than spread over several floors of one building. Using a virtual scribe was also described as a key comptent on the drive towards leaner practice management, and is especially important in light of the ongoing coronavirus pandemic. A virtual scribe is able to take a number of clerical duties away from medical staff, thus drastically reducing the amount of time they spend on records keeping. The concept is reported to be popular with patients too as these virtual scribes are designed to provide the highest quality of communication possible. The presentation given by Mr. Suneja was followed by a question and answer session where a number of issues were raised by the symposium’s viewers. These included the amount of time required for patient education, the cost of implementing a virtual scribe based system, and ensuring changes are compliant with the Health Insurance Portability and Accountability Act (HIPAA) in the United States.

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16 Nov 2020 | Issue #4

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CAKE & PIE POST (AAO 2020 Virtual Edition) - Issue 4  

CAKE and PIE magazines' Daily Congress News on the Anterior and Posterior Segments, AAO 2020 Virtual Edition.

CAKE & PIE POST (AAO 2020 Virtual Edition) - Issue 4  

CAKE and PIE magazines' Daily Congress News on the Anterior and Posterior Segments, AAO 2020 Virtual Edition.

Profile for mediamice