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HIGHLIGHTS Corner: 05 Executive Andrew Stewart of Allergan is in the house! eye drop against 07 An presbyopia has emerged ...

Cataract Surgery in Special Circumstances On Spotlight at AAO 2021 by Nick Eustice

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by Nick Eustice

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ataract surgery is among the safest, most common and least complicated surgical procedures performed in the world today. Millions of cataract procedures are performed each year by thousands of surgeons around the world, providing a swift and comparatively painless improvement in vision to countless patients, often in an outpatient setting.

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15 November 2021 | Issue #3

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conditions, in addition to extra health risks which this condition can bring on. Lastly, Dr. Malik spoke on the issue of eyelid growths, which vary quite drastically in size and in scope. These range from simple styes to malignant tumors. Because of the life-threatening dangers of such tumors, and the potential for complications with lesser growths, Dr. Malik urges doctors to address these issues before treating the cataract. Dr. Malik closed by encouraging all her fellow doctors to pay close attention to the intersections in areas of their patients’ care, in order to better support their overall health.

Given the prevalence and very high success rate of cataract surgeries, they are often considered pretty straightforward procedures. But cataracts often accompany a host of other ocular conditions that can make an otherwise simple procedure considerably more complex. In a symposium held on the third day of the American Academy of Ophthalmology’s (AAO 2021) annual meeting, a panel of expert surgeons shared their experiences of some of the challenges presented by these contemporaneous conditions. As these doctors described in the symposium, Cataract Surgery in Special Situations, a great many issues can arise during cataract surgery, especially when a variety of other, often more serious ophthalmic illnesses are present in a patient. These special situations often require extra care, and sometimes novel approaches.

Keeping a lid on cataract Before even considering simultaneously arising conditions within the eye, the panel’s first presenter focused on an area that might be easily overlooked by ophthalmologists: that of the eyelid. Dr. Amina I. Malik, a specialist in both ophthalmology and oculoplastics, delivered her presentation entitled, The Lens or the Lid: Which First?

Dr. Malik presented a number of different case studies involving patients whose eyelids were variously afflicted, and discussed the rationale in each situation on whether the eyelid condition should be treated first, or if the cataract should take precedence. In her first analysis, Dr. Malik described a patient who presented with both cataracts and ptosis, the drooping of the upper eyelid over the eye. The levator muscle shares several common fascial bands with the superior rectus muscle, which controls upper movement of the eye, so there is a 1-20% risk of ptosis occurring as a result of the insertion of the speculum or bridle suture used during cataract surgery. Because of this risk, Dr. Malik concluded that the cataract should be addressed first, as there is a significant chance of ptosis recurring as a result of the cataract. Three subsequent cases presented unique challenges which could complicate a cataract procedure. In cases of blepharoplasty and excessive tearing, there is a risk of fluid contamination following a cataract procedure. In both such cases, Dr. Malik says that these issues should be addressed prior to a cataract procedure. Similarly, patients exhibiting eyelid edema should have this issue treated first, for the same fluid issue potentialities of the previous two

Glaucoma and cataracts: A challenging combination Later in the symposium, Dr. Arindel S. Maharaj spoke on the intersection of cataracts and another major topic in ophthalmology: glaucoma. These two conditions, while quite different in their effects, share a troubling relationship. About 20% of patients with cataracts also have glaucoma. This can come about through mere coexistence, however Dr. Maharaj pointed out that cataracts can give rise to glaucoma; meanwhile glaucoma surgery can sometimes in turn cause cataracts. Because of the reciprocal danger posed by these conditions, Dr. Maharaj focused his lecture on the pros and cons of treating the two issues at once. On the one hand, there are numerous benefits that can be associated with performing cataract surgeries in glaucoma patients. The combined procedure typically produces a very significant improvement in the patient’s vision. The cataract surgery provides additional control over the patient’s intraocular pressure (IOP) and provides a deeper anterior chamber, both of which allow for greater alleviation of glaucoma symptoms. Lastly, the combined procedure cuts down on the number of surgeries which the patient has to go through. However, this combination of surgeries


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

is not without its drawbacks. While one surgical visit is more convenient for the patient, it is of course a much longer procedure. There is a higher risk of complications from such a complex and prolonged procedure, due not just to the length of the surgery, but also the greater number of areas being operated on. The combined procedure also makes the refractive outcome less controlled and less predictable. Because many factors can influence the decision of whether or not to treat glaucoma and cataracts at once, Dr. Maharaj suggests evaluating the pros and cons on a case-by-case basis, taking into consideration the severity of the patient’s glaucoma, the urgency of the treatment, and the patient’s preferences.

Considerations with other areas of the eye Three other speakers spoke of the relationship between cataract surgeries and diseases of other specific areas of the eye. Dr. John Chen spoke on his experiences treating two issues of neuroophthalmic disease which can arise following cataract surgery: double vision and vision loss.

patients with cataracts. As the corneal tissue is directly involved in cataract surgery, Dr. Al-Mohtaseb shared many accounts of her successful experiences in combining the two procedures.

Putting the patient first

“It’s really about the patient discussion and patient expectations: I hope we brought that very important point for all the different subspecialties.” — Dr. Al-Mohtaseb The simultaneous discovery of multiple visual impairments can also

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“It’s really about the patient discussion and patient expectations: I hope we brought that very important point for all the different subspecialties,” Dr. Al-Mohtaseb said in concluding the symposium. She finished by thanking all of the speakers for helping the audience to think outside their subspecialties, and to consider the broader health of the patients when confronting different issues at the same time.

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Beyond the health of the patient, the next recurring theme is that of the patient’s expectations. Cataract patients are always eager to experience a restoration of their visual acuity. Though the continuing visual impairment caused by a cataract may lead to a patient’s disappointment after treating a more serious condition first, it is important to counsel patients about the need to address more time sensitive and threatening issues in order to preserve their long-term vision, or even save their life.

Overall, a number of themes emerged throughout the various lectures in this symposium. Whatever other conditions may accompany cataract surgery, the primary concern is always the overall health of the patient. While this is true any time a medical procedure is carried out, it’s especially vital to keep this in mind when more than one illness is present.

Dr. Roomasa Channa spoke on the topic of retinal diseases in conjunction with es ocular conditions cataract surgeries. The studies Dr. l i ke etim m ca so Channa presented indicate ta ll y, ra e j ct a high level of confidence d a an in positive outcomes for patients suffering from diabetic macular edema (DME), diabetic retinopathy and agerelated macular degeneration (AMD) when undergoing cataract surgeries.

e r t o o…

Lastly, the symposium’s chair, Dr. Zaina N. Al-Mohtaseb, presented her experiences treating corneal disease

be extremely taxing for a patient, and presents a substantial challenge to their doctor, as well. When two such issues arise at once, even relatively straightforward procedures like cataract surgery can present unique challenges.

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15 November 2021 | Issue #3

Hot Topics Session Provides Spicy Ophthalmology Takes by Andrew Sweeney

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ew Orleans is famous for its food, whether that be jambalaya, gumbo, or something else, it’s a place where if you like food, you’re going to fit right in. At Media MICE, we like our food hot — and we also like hot topics in ophthalmology, so fiery debates keep our intellectual palates salivating for more. On Day 3 of the American Academy of Ophthalmology’s (AAO 2021) annual meeting, we got exactly what we were hoping for, a spicy session of hot takes in ophthalmology. Hot Topics 2021 brought us the best “dishes” ophthalmology has to offer on a number of exciting and crucial issues. Covering everything from artificial intelligence in medicine, to corneal neurotization, and the use of telemedicine technology for glaucoma monitoring, this

is one session you don’t want to miss on demand. Just make sure you’ve got a side of sugar on hand to tone down the spice. Corneal neurotization just sounds really cool, but that’s not why we want to draw your attention to this presentation by Dr. Ilya Leyngold, an associate professor at the Duke University Eye Centre (Durham, North Carolina). Rather, it was because of the doctor’s highly insightful information on the efficacy of his presentation topic, noting that 92% improvement in visual acuity can be observed after the application of neurotization. He also noted that it’s durable, with one patient experiencing 18 years of corneal improvement and stabilization. Plus his report had some seriously fantastic surgical footage, kudos!

Another standout from this spiciest of sessions was about glaucoma monitoring at the home, presented by Dr. Oluwatosin U. Smith, an ophthalmologist at Glaucoma Associates of Texas (Dallas). We have all become more familiar with telemedicine since the COVID-19 pandemic began and Dr. Smith made some good arguments as to why domestic monitoring is beneficial to patients and clinicians, alike. Her hot takes included her position that at-home monitoring allows for the identification of rapid progressors and it identifies spikes and fluctuations in intraocular pressure, although she admitted that pricing issues still need to be considered. Spicy! We know that you can handle the heat, so make sure you check out this session on AAO’s on-demand platform and spice up your ophthalmological life with more hot takes. The other speakers of the session also have their own peppery presentations, which you will no doubt find perfectly suited for your palate. Let us know what you think, and remember, if you can’t handle the heat, stay out of the clinic.


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

Executive Corner

Q&A with

Andrew Stewart of Allergan, an AbbVie Company by Brooke Herron

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phthalmic conferences, like the AAO 2021, offer unique opportunities to meet with some of the industry’s executive thought leaders. During the show, we had a chance to sit down with Andrew Stewart, general manager of global business for Allergan, an AbbVie company, for his perspective on how the pandemic has affected eye care.

Media MICE (MM): Are you excited to be back to in-person meetings? Andrew Stewart (AS): It’s great to be at meetings where you actually get a chance to connect in-person. I believe you enlist a higher level of commitment to one another as individuals; you have

a much faster path of establishing trust with each other when you have the opportunity to interact and to build those relationships in-person.

MM: What are some of the benefits of in-person meetings, versus Zoom calls, for example? AS: One of the added benefits when you’re face-to-face are the spontaneous things that occur, like impromptu discussions that arise. In-person, there is a much more free-flowing, easier exchange of ideas. In the Zoom world, everything is so scheduled, so deliberate, and so calculated as to when it starts when it ends, and it’s very

boxed in — and I think that prevents you from really getting a chance to have those more organic discussions.

MM: And with in-person meetings, you can have drinks or dinner — spontaneous things — which help build these relationships, as well. AS: Absolutely. At the start of the pandemic, so many people felt that “we’re never going back, we’re going to change forever, congresses are going to become virtual environments, so are ad boards. That in-person experience is dead and gone forever.”

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15 November 2021 | Issue #3

I think it’s exactly the opposite: I think you have a pendulum that has swung entirely too far one way and right now, it is going to reverberate back pretty hard. People are missing that in-person connection and interaction.

we had about 30 physicians participate in-person and then we had four other satellite locations throughout the U.K. This allowed us to extend participation to nearly 200. If we only had that one site in London, maybe we would have gotten 50-60, but we never would have reached 200.

MM: So, has Allergan, an AbbVie company, shifted MM: Do you think you how it approaches these events since the pandemic would have had this hybrid model without the started? pandemic’s influence? AS: One of the things that we are all experiencing, certainly you and I, is interacting wearing a mask, by having to take a test, by having to show proof of vaccination — all of these other hurdles that still exist. Of course, first and foremost is making sure we have employee safety in mind and safety within the community we’re working with. We also have new hybrid models where we have in-person and other telecom presences that enrich participation even more. I was recently in the U.K. for our Beyond Retina event, a symposium where retina physicians talk about practice dynamics, as well as treatment algorithms, opportunities and options for patients and physicians, alike. We had a homebase in London where

AS: No chance — the pandemic has absolutely influenced this. If it wasn’t for the pandemic, we would have had one location in London and we would have celebrated the fact that we had 60-70 participants involved. Instead by having a hybrid model, we were able to get to 200. So, it’s absolutely a multiplier.

MM: Moving on to AAO 2021, where does this show fit into Allergan, an AbbVie company’s, global strategy? AS: AAO is a prominent and very important congress for Allergan, now an AbbVie company. We have

programs lined up across all of the specialties that we participate in to show the diversity of our portfolio, and where we really fit within the eye care community. Now we’re part of a larger organization within AbbVie, but Allergan has been in eye care for 70 years. And there are people that are connected to the legacy of the company, even from the start. Certainly our founder Gavin Herbert is still present within the eye care community. There’s many people within the legacy company that have been employees for 20-25, even 30 years, and they really understand the continuity of the business, they are customer-focused and very much part of the fabric of what eye care really is. It’s very unique and it’s our heritage — and a legacy that I’m certainly proud to be a part of. It drives a level of commitment and responsibility.

MM: And finally, what are you looking forward to most in New Orleans? AS: The food and the experience, the weather, the chance to do some real work with our colleagues, the opportunity to enjoy the city a little bit, to get out and have a cocktail and enjoy the Cajun food, for sure.


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

See Clearer Treat Presbyopia With an Eye Drop by Nick Eustice

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e hear a lot of terms for ocular conditions thrown around, but presbyopia isn’t the most common one. There are a few reasons for this: Presbyopia isn’t an acutely dangerous condition like glaucoma, or a cause for frequent surgical treatment like cataract. Rather, presbyopia is incredibly common, and for this reason we just don’t hear about it every day. Presbyopia causes difficulty in near vision and occurs with age. It’s so widespread that upwards of 85% of people over the age of 40 suffer from it.* Its commonality and virtual inevitability are a big reason why it isn’t normally addressed as a medical problem per se, but rather just as another natural part of getting older. And its treatment — usually with reading glasses — is so ingrained in our daily lives that a rack of such glasses, inexpensive and requiring no prescription, is a common sight in most pharmacies. The cause of presbyopia is not fully understood. Researchers believe that it is most likely due to a weakening of the ciliary muscles, or to a hardening of the lens over time that results in diminished elasticity. In either case, the eye experiences an increasing difficulty in changing its point of focus. This results in blurring of vision in the very near field. While most commonly associated with difficulty reading fine print, presbyopia also causes difficulty with other tasks such as threading needles and using our ever-more ubiquitous smart phones. Most people have come to accept that this is just a normal part of aging. But the fact that a condition is common and somewhat tolerable doesn’t mean it should be overlooked. And as the body of knowledge available to the ophthalmic community grows, we begin to see treatments become available for conditions like presbyopia along with the bigger, more dangerous ones we hear much more about. And there’s ample reason for this: Who wouldn’t want to improve their diminishing near-field vision?

The first big news in this area came late last month, when the FDA approved VUITY, a new eye drop medication developed by Allergan, an AbbVie company. VUITY is a formulation of pilocarpine, an anticholinergic which causes dilation of the pupil to improve focus on nearby objects. It is the first medication ever approved for the treatment of presbyopia. “Most adults cope with presbyopia, or difficulty with near vision, as we age. Beginning around the age of 40, many find themselves using reading glasses, holding text further away, or even increasing the font size and lighting on screens to try to see more clearly,” said Michael Severino, MD, vice chairman and president, AbbVie. “We are proud to offer VUITY as a first-of-its-kind, oncedaily eye drop that we believe will change the way people and their eye doctors approach presbyopia. The FDA approval of VUITY exemplifies our continued pursuit of innovative new treatments that push the boundaries of what’s possible in eye care.” The FDA’s approval of VUITY came as a result of the GEMINI I and II studies which evaluated the drug’s effectiveness in treating presbyopia. At this year’s Academy of American Ophthalmology (AAO 2021) annual meeting in New Orleans, Dr. George O. Waring presented findings from the pivotal third phase of these studies. Dr. Waring’s original paper, entitled PA031 GEMINI 1 and 2 Pooled Phase 3 Safety and Efficacy: AGN-190584 Primary and Key Secondary Endpoints, was presented at the meeting. In this phase of the studies, 750 presbyopia sufferers between the ages of 40 and 55 were separated into two groups, either receiving one daily, self-administered drop of VUITY or placebo. In both studies, a statistically significant proportion of

participants treated with VUITY gained the ability to read three additional lines in low light, high contrast, binocular distance corrected near visual acuity (DCNVA), without losing more than 1 line (5 letters) of corrected distance visual acuity (CDVA) on a reading chart, compared to those who had received the placebo. In addition to the documented improvement in patients’ near-field sightedness, and perhaps a lot more importantly, no serious adverse side effects were reported by any participants who received VUITY drops. Only a small number of patients reported non-serious side effects, including eye redness and headaches. Full details on VUITY’s dosages, chemical composition, and specific trial findings can be found here. This highly-encouraging news means that eye care professionals will soon be able to prescribe what once seemed like a miracle cure: Eye drops that can reduce or even eliminate the need for reading glasses. For over 128 million Americans, nearly half of the U.S. adult population, and the countless others throughout the world for whom presbyopia has become an accepted burden of daily life, this is very good news indeed. For the first time ever, there is a real possibility of treating blurred near-field vision without the use of corrective lenses. You can read the official announcement here, along with some other exciting trial results.

* Katz JA, Karpecki PM, Dorca A, et al. Presbyopia – A Review of Current Treatment Options and Emerging Therapies. Clin Ophthalmol. 2021; 15: 2167–2178.

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