August 27, 2012 Annual Meeting Highlights
Monday
On Monday, the 30th ASRS Annual Meeting featured the:
- Diabetic Retinopathy I Symposium
- Ocular Oncology
- Socioeconomic Sessions
- AMD II Symposium
- Retinal Surgery I Symposium
Retina Image Bank : Image of the Day
Condition: Congenital optic nerve pit
Uploaded by: John S. King, MD
Photographer: Kristin Konecki, OcuSight Eye Care Center, Rochester, NY
Imaging device: Fundus cameras
Diabetic Retinopathy I Symposium
Monday, August 27, 7:30-9:26 AM
Moderators: Peter Kaiser, MD, Carl Regillo, MD, FACS
Reported by Joel Pearlman, MD, PhD
Sacramento, California
A Novel Collaborative Multicenter Telemedicine Diabetic Retinopathy Assessment Program
Presenter: Ingrid Zimmer-Galler, MD
Zimmer-Galler, et al imaged 1,151 patients with a remote non-mydriatic camera to test the feasibility of a telemedicine screening program; 25% had diabetic retinopathy and 41% had non-diabetic retinopathy ocular findings, suggesting that telemedicine screening is a viable solution.
Identification of Diabetic Retinopathy Genes Through a Genome-Wide Association Study Among Mexican-Americans
Presenter: Victor Gonzalez, MD
Using a genome-wide association study, Gonzalez, et al identified numerous genetic susceptibility loci for severe diabetic retinopathy in the Mexican-American population with Type 2 diabetes.
One of these genes was associated with ATF-2 induced insulin gene expression; another was involved in adhesion of epithelial cells. They have much exciting work ahead of them.
Navigated Macular Laser Therapy Results in Stabilizing Diabetic Macular Edema (DME)
Presenter: William Freeman, MD
This retrospective study compared navigated laser with bevacizumab injection to navigated laser alone for diabetic macular edema. Adding laser stabilized visual gains and reduced the need for retreatment in eyes with thickening greater than 439 microns.
Intravitreal Bevacizumab for Recurrent Vitreous Hemorrhage After Vitrectomy for Diabetic Retinopathy
Presenter: Mathew MacCumber, MD, PhD
This retrospective review of the use of intravitreal bevacizumab for recurrent vitreous hemorrhage in post-vitrectomy PDR eyes showed a reduced need for reoperation. Blood generally cleared within 6 weeks of injection.
Rapid Progression of Proliferative Retinopathy Despite Extensive Panretinal Photocoagulation: Could Early Vitrectomy Have Saved the Eye?
Presenter: Anina Abraham, MD
Six gnarly cases of severe progressive proliferative diabetic retinopathy despite excellent PRP were presented. The thought was presented that aggressive PDR with taut hyaloid might require early vitrectomy as PRP alone might worsen traction.
Transvitreal Fibrinoid Pseudo-endophthalmitis After Diabetic Vitrectomy
Presenter: Caesar Luo, MD
Transvitreal fibrinoid response is sometimes seen post-diabetic vitrectomy. While this should be distinguished from endophthalmitis, many cases resolve spontaneously.
36-Month Efficacy and Safety Results of RISE and RIDE, 2 Phase III Randomized Controlled Clinical Trials of Ranibizumab for Diabetic Macular Edema
Presenter: David Brown, MD
In his inimitable style Dr. Brown presented the 36-month efficacy and safety results of RISE and RIDE. He reminded us of the significant social morbidity associated with diabetes and showed that both ranibizumab 0.3 mg and 0.5 mg administered monthly led to substantial decreases in macular thickness and increases in visual acuity of 10.5 to 14.2 letters over 3 years.
Time to development of PDR was also delayed in patients receiving anti-VEGF treatment. The safety profile was excellent and no new ocular or systemic safety concerns for intravitreal ranibizumab were raised. Early treatment led to better final visual acuities.
A Prospective Randomized Trial of Intravitreal Bevacizumab versus Ranibizumab for the Management of Diabetic Macular Edema
Presenter: Rodrigo Jorge, MD
This was a very good paper demonstrating that both intravitreal bevacizumab and ranibizumab reduced central subfield thickness and improved vision in patients with diabetic macular edema over 48 weeks. Fewer injection of ranibizumab (7.7) than bevacizumab (9.9) were required for this effect.
0.5 mg and 2 mg Ranibizumab in Patients Unresponsive or With Incomplete Response to Bevacizumab for the Treatment of Diabetic Macular Edema
Presenter: Dante Pieramici, MD
Dr. Pieramici presented preliminary results from the REEF trial, showing that some diabetic macular edema patients who do not respond favorably to intravitreal bevacizumab may respond to low (0.5 mg) or high (2.0 mg) ranibizumab treatment.
Estimate of Vision of Impairment or Legal Blindness Avoided in the U.S. With Ranibizumab for Central-Involved Diabetic Macular Edema With Vision Loss
Presenter: Neil Bressler, MD
Dr. Bressler presented the societal implications of intravitreal ranibizumab therapy for central involved diabetic macular edema in the non-Hispanic white and Hispanic patients in the United States. He demonstrated that 33% of patients avoided visual impairment with treatment and 29% avoided 20/40 or worse. Seventy-eight percent of treated patients avoided legal blindness.
Integrin Peptide Therapy: The Human Experience in DME
Presenter: Hugo Quiroz-Mercado, MD
Dr. Quiroz-Mercado presented an intriguing Phase I study on the use of a single intravitreal injection of a synthetic integrin oligopeptide for DME. The drug acts in various aspects of the angiogenic cascade independent of VEGF and appears to have some effect on PVD formation.
Eight of 15 patients demonstrated 3 lines of visual improvement as well as reduction in central macular thickness. A Phase Ib/2a wet-AMD study is underway. The drug may provide beneficial complementary treatment to currently available therapies.
Visual Acuity and OCT Outcomes Following Cataract Extraction in Eyes With Diabetic Macular Edema
Presenter: Michael Scott, MD
This update from the DRCR.Net looked at the outcomes of cataract surgery in patients with preexisting and concurrent DME. While patient recruitment presented a significant challenge, worsening thickness occurred in only a minority of patients (15%) and average visual acuity improved 12 letters. Overall visual results were less favorable than expected for patients without preexisting macular edema.
Risk of Endophthalmitis After Intravitreal Drug Injections With and Without Use of Topical Antibiotics in DRCR Randomized Clinical Trials
Presenter: Abdhish Bhavsar, MD
Seven cases of endophthalmitis following intravitreal injection in the DRCR.Net were reviewed as well as the prophylaxis technique. No good evidence that topical antibiotic reduced the chance of endophthalmitis was found.
Ocular Oncology
Monday, August 27, 9:26-9:46 AM
Moderators: Tara McCannel, MD, PhD, Peter Reed Pavan, MD
Reported by Prithvi Mruthyunjaya, MD
Durham, North Carolina
Intravitreal High-Dose (2 mg) Ranibizumab for Recalcitrant Radiation Maculopath
Presenter: Paul Finger, MD, FACS
Dr. Finger reported results of a prospective series of 10 patients with radiation maculopathy (RM), refractory to standard dose anti-VEGF medications, who were then treated with 2.0mg ranibizumab injections.
Visual acuity was essentially stabilized, but anatomic thickening was improved or reversed in the majority of patients.
This suggests that refractory RM may benefit from a greater degree of VEGF inhibition than with standard dosing.
Outcomes After Plaque With Vitrectomy and Silicone Oil for Choroidal Melanoma
Presenter: Tara McCannel, MD, PhD
Dr. McCannel has pioneered a procedure to address the problem of radiation-related damage from plaque brachytherapy by combing plaque placement with concurrent pars plana vitrectomy and 1000 sc silicone oil tamponade (PPV/SO).
Nineteen patients with 1-year follow-up and well-matched controls were compared: Tumor control was similar but macular retinopathy was significantly improved, safely, with PPV/SO.
SO is known to reduce radiation scatter in eyes, so this combination procedure may hold promise to reduced complications of plaque therapy, though continued validation is needed.
Socioeconomic Sessions
Monday, August 27, 10:16-11:51 AM
Moderators: Timothy Murray, MD, MBA, Trexler Topping, MD
Reported by Prithvi Mruthyunjaya, MD
Durham, North Carolina
Accountable Care Organizations: What You Don't Know May Hurt You
Presenter: William Rich III, MD
Dr. Rich gave an overview of the history and tenets of the Affordable Care Act. Retina subspecialists may be initially protected from quality an outcome metrics. As these are more likely to be linked with care delivery models, it will be important to optimize these measures to ensure referrals from primary care doctors as well as reimbursement.
Risks and Opportunities From Health Care Reform
Presenter: Paul Sternberg, MD
As Affordable Care Organizations may take some time to become widespread, Dr. Sternberg reviewed the Clinically Integrated Networks (CINs) as a model of how to function in future capitated health care plans. CINs empower networks to reduce costs while ensuring measured outcomes with participants sharing cost savings and profits.
Retinal physicians will need to demonstrate the value of their services and may be forced to rethink testing frequency and drug costs in managing their patients.
FDA Approval Process for Ophthalmic Drugs Used to Treat Retinal Diseases
Presenter: Wiley Chambers, MD
Dr. Chambers provided an insightful overview of the FDA drug approval process. He highlighted safety problems from previously approved and off-label drugs and identified diseases where new drug applications are needed.
Real-World Utilization of Intravitreal Antivascular Endothelial Growth Factor Agents in Retinal Diseases: A Claims Analysis from 2006 to 2011
Presenter: Nancy Holekamp, MD
An analysis of a large longitudinal cohort of billing claims of patient with AMD, DME, and RVO found that the number of anti-VEGF injections was less (on average 2 to 6 injections/year) than the monthly frequency recommended by clinical trials.
It is unclear why the "real-world" treatment frequency is low and also if these patients have the same visual or anatomic benefit as reported in clinical trials.
Practice Analytics in Retina Practice Management
Presenter: Trexler Topping, MD
Dr. Topping described a custom-designed, non-commercially available practice analytics program utilized by his practice to centralize key metrics including patient transit times, scheduling, and financial data.
By integrating this data into a "practice dashboard," the practice better understands key areas for improvement and can help the individual physician modify practice patterns to improve productivity.
Socioeconomic Panel Discussion
Presenter: Trexler Topping, MD
Moderator: Reginald Sanders, MD
Panelists: Johnathon Prenner, MD, Larry Halperin, MD, David Brown, MD
Panel members representing 7 large multi-physician retina practices offered diverse perspectives on partnership compensation, handling retirement of a practice member, negotiating insurance contracts, marketing, and profitability of clinical trials.
AMD II Symposium
Monday, August 27, 1:05-3:14 PM
Moderators: David Brown, MD, Julia Haller, MD
Reported by Chirag Shah, MD, MPH
Boston, Massachusetts
96 Weeks Results from the VIEW 1 and VIEW 2 Studies: Intravitreal Aflibercept Injection versus Ranibizumab for Neovascular AMD
Presenter: Allen Ho, MD
2457 patients were randomized to ranibizumab q4 weeks, aflibercept 0.5 mg q4 weeks, aflibercept 2mg q8, or aflibercept 2 mg q4 weeks. In the second year, patients were treated PRN with a minimum of quarterly aflibercept injections. There was a similar treatment effect in all 4 treatment arms, with faster resolution of fluid in the 2 mg aflibercept arms.
The Incidence of Non-Infectious Intraocular Inflammation after Intravitreal Aflibercept Injection
Presenter: Daniel Roth, MD
After a total of 2856 aflibercept injections, 8 eyes had inflammation, 3 of which were felt to be endophthalmitis.
VEGF Trap-Eye (Aflibercept) Effectiveness in Wet AMD Patients Recalcitrant to Ranibizumab and Bevacizumab
Presenter: Vincent Hau, MD, PhD
In 41 eyes of patients with residual fluid after anti-VEGF treatment, there was decreased mean subfoveal thickness and improved vision after 3 aflibercept injections.
The Initial Response to Aflibercept for Neovascular AMD with Persistent Fluid on OCT (Non-Responders)
Presenter: Patrick Williams, MD
53 eyes with persistent fluid on OCT despite a minimum of 3 prior injections, most recently within 4 months, had improved central subfoveal thickness after one aflibercept injection.
Resolution of Persistent Macular Edema, SRF and/or RPE Detachment After Single Injection of Aflibercept in Patients with Neovascular AMD
Presenter: Ashish Sharma, MD, FACS
Ninety-three eyes with persistent fluid after anti-VEGF treatment (average of 19 prior injections), 41% had resolution of fluid after 1 aflibercept, 13% had partial resolution, 31% with improvement, and 15% with no change; 41% had visual improvement.
Pigment Epithelial Detachment Improvement in Non-Naive Neovascular AMD Patients After Intravitreal Aflibercept
Presenter: James Major, MD, PhD, FACS
Seventy-four patients with persistent PEDs due to CNVM from wet AMD on prior anti-VEGF treatment exhibited a 15.5% decrease in PED volume at 1 month after aflibercept. The number of prior injections was associated with treatment response.
Aflibercept for Patients Previously Treated With Anti-VEGF Therapy for Age-Related Macular Degeneration
Presenter: Irene Barbazetto, MD
Sixty-one eyes with an average of 18 prior injections with persistent fluid had a significant reduction of central subfoveal thickness and a trend toward better vision 1 month after crossover to aflibercept.
Initial Experience With Aflibercept in the Management of Patients With Persistent Exudation Due to AMD Undergoing Chronic Ranibizumab Therapy
Presenter: Kirk Packo, MD, FACS
Twenty patients had chronic recalcitrant fluid on at least 6 consecutive visits after an average of 25 ranibizumab injections, minimum of 6. After 1 aflibercept, 65% were completely dry, 15% were improved, 10% had no change, and 10% were worse.
Intravitreal Aflibercept in Eyes with Active Choroidal Neovascularization (CNV) Secondary to AMD After Multiple Ranibizumab or Bevacizumab Injections
Presenter: H. Wheatley, MD for Jonathon Prenner, MD
Forty-three eyes with persistent fluid showed improved central subfoveal thickness, macular volume, and visual acuity after 1 aflibercept; 54% showed response.
Aflibercept for Exudative AMD Suboptimally Responsive to Ranibizumab and Bevacizumab
Presenter: Chirag Shah, MD, MPH
Seventy-nine percent of patients (123 of 155) with persistent fluid after an average of 15 regular ranibiuzmab and/or bevicizumab treatments demonstrated anatomic response to a single aflibercept injection.
Initial Early Clinical Experience With Aflibercept for Wet Age-Related Macular Degeneration
Presenter: Philip Ferrone, MD
There were 250 total patients treated with aflibercept. There was an improvement in vision in treatment-naïve patients. There was an improvement in OCT in previously treated and treatment-naïve patients.
Improvement in Diabetic Retinopathy(DR) Associated with 0.2mg/d Fluocinolone Acetonide (FA) Treatment for Chronic Diabetic Macular Edema (DME)
Presenter: Pravin Dugel, MD
Patients with chronic, severe diabetic macular edema responded to 0.2mg fluocinolone implant; 4.8% needed incisional IOP surgery. The majority of phakic patients needed cataract surgery.
Visual and Anatomic Outcomes of Anti-VEGF Therapy in Exudative AMD and Vitreomacular Interface Disease
Presenter: Sophie Bakri, MD
In 187 patients with wet AMD treated with 3 monthly injections followed by PRN treatment, there were more injections given to patients with VMT or ERM without differences in vision or central subfoveal thickness, despite a higher CST at baseline in patients with VMT/ERM.
Quantitative Determination and Comparison of Intravitreal Cytokines in DRP, RVO and ARMD
Presenter: Michael Koss, MD
One hundred eighty-seven eyes underwent 23g monoport vitrectomy to evaluate intravitreal cytokines. VEGF levels were highest in DME and RVO. For AMD, VEGF levels were similar to controls. MCP-1 was highest in AMD samples.
Retinal Surgery I Symposium
Monday, August 27, 3:44-5:24 PM
Moderators: Carl Awh, MD, Virgillio Morales-Canton, MD
Reported by Nicholas Engelbrecht, MD
St. Louis, Missouri
Vitreoretinal Traction and Effectiveness of a Modified Vitrectomy Probe in Small-Gauge Vitrectomy: Experimental and Clinical Study
Presenter: Stanislao Rizzo, MD
Vitrectomy probe was modified by creating a hole in the cutter to allow for flow during "closed" state. Modified vitrectomy probe showed greater suction power and reduced retinal traction.
Two-Year Results from the Argus® II Retinal Prosthesis System Clinical Trial
Presenter: Mark Humayun, MD, PhD
The Argus II implant trial has shown acceptable safety profile, implant durability and providing some functional vision; 27% of patients showed greater than 3 lines of visual improvement from baseline vision.
Best vision in one patient measured using gradient visual acuity was 20/1620, improved to 20/200 with 8X magnification. Some color distinction was also demonstrated.
Combined Vitrectomy With Gas Tamponade and Posterior Glaucoma Tube Placement in the Management of Complicated Uveitic Glaucoma
Presenter: E. Opremcak, MD
Combined vtrectomy with pars plana tube placement showed improved IOP and reduction of need for topical glaucoma drops; 65% of patients showed no recurrence of uveitic activity after vitrectomy.
Rate of Sclerotomy Suturing in 23-Gauge and 25-Gauge Vitrectomy Surgery
Presenter: Kourous Rezaei, MD
Overall suture rate was 57.4%.
Air/gas tamponade significantly reduced suture rate.
High amount of variability among surgeons for suture rates.
Suture rate was increased with more extensive surgery.
Suture rate was 45.3% for 25 ga and 38.5% for 23 ga.
Evaluation of Wound-Closure Morphology of Sclerotomy Sites Using Anterior Segment Spectral-Domain Optical Coherence Tomography (AS OCT)
Presenter: Manish Nagpal, MD, FRCS (UK)
Anterior-segment SD-OCT showed progressive reduction in sclerotomy size from day 1 to day 30.
Wound Closure Evaluated With Optical Coherence Tomography After 25-Gauge Vitrectomy
Presenter: Makoto Inoue, MD
OCT with longer wavelength is more useful for evaluation of wound closure and OCT, with shorter wavelength more useful for evaluation of ciliary body detachment.
Translational Development of a Subretinal Delivery System for Cell-Based Products
Presenter: Michael Samuel, MD
Early use of catheter with transretinal approach resulted in unacceptable complication rate with occurrence of tractional retinal detachment. Safety of modified technique using transcleral approach into subretinal space improved with endoscopic visualization of creating retinal bleb.
Risk of Iatrogenic Retinal Tears in Small-Gauge Vitrectomy (PPV) Is Reduced by Initiating Surgery With Peripheral PPV Rather Than Traditional Core PPV
Presenter: Renaud Duval, MD, FRCS(C)
Results suggest reduced rate of retinal tears in eyes without pre-existing PVD possibly due to minimizing anterior-posterior retinal traction early in the case.
Novel Changes to Retinal Anatomy as Imaged by Intraoperative Optical Coherence Tomography During Repair of Rhegmatogenous Retinal Detachment
Presenter: Matthew Ohr, MD
Dr. Ohr evaluated macula-off retinal detachments. OCT showed residual subretinal fluid in 100% of eyes after perfluorocarbon liquid. Alteration of foveal configuration was noted during retinal detachment repair.
A Mechanics-Based Model of a Detaching Retina
Presenter: Howard Fine, MD, MHSc
Dr. Fine demonstrated a mathematical model of mechanics of the detaching retina.
Unplanned Return to the Operating Room Following Vitreoretinal Surgery
Presenter: Jay Stewart, MD
Return-to-OR rate was 3.8% at 30 days and 9.6% at 90 days. Information most useful as measuring quality at a single institution and not for comparison of institutions.
Ophthalmicedge.org Version 2.0: Expansion and Analytics of a Free Educational Website
Presenter: Yale Fisher, MD
Educational website allows dynamic and interactive use and access to recognized experts.
Determining Construct Validity of the Posterior Segment Anti-tremor, Bimanual, and Forceps Training Modules on the EYESi Virtual Reality Simulator
Presenter: Colin McCannel, MD
A learning curve for retinal surgery simulator is present for both novice and experienced surgeons. The learning curve may mask construct validity.
Combined Scleral Tunnel Fixated Posterior Chamber Intraocular Lens and Pars Plana Vitrectomy in the Management of Posteriorly Dislocated Lenses
Presenter: Edmund Wong, MBBS, MMed, FRCS
Results showed a stable lens with good dentration, and a lower complication rate compared with other second implant placement procedures.
Posters
Reported by Andrew A. Moshfeghi, MD, MBA
Palm Beach Gardens, Florida
Practice Management/Coding/Computers
501: James Maisel evaluated natural language processing of dictated reports and determined that preliminary tests indicate that an electronic health record documentation that applies (NLP) to dictated text removes the otherwise necessary loss of speed while maintaining quality of data collection.
502: Darius Moshfeghi and colleagues collected demographic and epidemiologic data from a typical retina clinic in an academic setting. Diabetes was the leading cause of referral at every age group and was the primary diagnosis for patients aged 11 to 70.
503: Wafapoor and Eaton evaluated a Web-based non-emergent system to facilitate patient referral between offices in a seamless manner. Their beta system is HIPAA-compliant and enables tracking of referrals.
Risk Management
504: Nader Moinfar created a surgical safety checklist for vitreoretinal surgery that could be used by vitreoretinal surgeons to reduce the likelihood of physician errors. This was based on a modified World Health Organization checklist. Validation studies with this modified checklist are pending.
505: Chang Nguyen and colleagues described the clinical manifestations of intravitreal bortezomib (chemotherapy agent indicated for the treatment of multiple myeloma). They observed fibrinous anterior uveitis, choroidal detachment, corneal edema, angle closure glaucoma, severe retinal vascular attenuation, optic atrophy, and retinal infarction and detachment. In addition, extensive ERG changes were observed in patients who were inadvertently injected with this medication due to a compounding error.
Socioeconomics
506: Andrew Moshfeghi and colleagues analyzed data from the Florida State Ambulatory Surgery Database and determined that utilization of ambulatory surgery centers (ASCs) by vitreoretinal surgeons in Florida increased by 34% annually between 1999 and 2008.
507: Christina Leung and colleagues determined that government restrictions on ranibizumab use for diabetic macular edema (DME) in Canada in 211 resulted in poorer visual outcomes for those with center involved DME who were unable to continue ranibizumab therapy.