Eyeworld

DEC 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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December 2012 ���It���s an ethical versus economic question,��� he said. ���Genetic testing can be a good way to modify a patient���s environmental risk,��� such as smoking, and the testing may be able to ease a patient���s anxiety if he or she does not show proclivity for the genes. Other benefits may include the fact that physicians can begin prophylactic treatments earlier and may be able to identify early stage disease quicker to provide a basis for modification. ���These tests are expensive, but insurance does cover them,��� he added. Taking the opposing view, Frederick L. Ferris, M.D., Waxhaw, N.C., countered if the purpose of genetic testing is for research, then it should be endorsed. ���But at this time, it���s questionable if routine genetic testing is useful to individuals in understanding their risk of disease��� because clinicians have a fairly easy method to identify risk (determining if drusen is more than 125 microns in diameter and determining if there are pigmentary changes; combinations of these two factors in both eyes will yield reliable risk potential for developing AMD). ���If you do genetic testing, you���re obligated to provide genetic counseling,��� Dr. Ferris said. He added that the American Academy of Ophthalmology has recommended against routine genetic testing for AMD. An audience poll after the debate showed 92% of respondents agreed that routine genetic testing for AMD is not likely to enter their clinical practice. Editors��� note: Dr. Blumenkranz has financial interests with Avalanche Biotechnology, Digisight, OptiMedica, Vantage Surgical, and ISTA Pharmaceuticals. Dr. Ferris has financial interests with Bausch + Lomb. Numerous dry AMD treatments under development Drugs that suppress inflammation and drugs that improve choroidal circulation and protect against ischemia, drugs that protect photoreceptors and provide neuroprotection, and drugs that modulate the visual cycle are all under development for the treatment of dry agerelated macular degeneration (AMD), a condition for which there are no approved pharmacologic therapies. David M. Brown, M.D., Houston, and Philip J. Rosenfeld, M.D., Miami, discussed the various drugs in development, including fenretinide (ReVision Therapeutics), which had completed a Phase IIb study but because of manufacturing issues with the compound will have to re-run the entire study. Smoking cessation and diet supplementation are the only currently recommended interventions for slowing disease progression to choroidal neovascularization, and several of the compounds under development seem to be based on the pathogenesis of AMD, they said individually. Both physicians believe a ���treatment breakthrough��� may occur in the next decade. Editors��� note: Dr. Brown has financial interests with Alcon, Allegro, Allergan, Bayer, Eyetech, Genentech, Glaukos, GlaxoSmithKline, iCo Therapeutics, Neurotech, Novartis Pharmaceuticals, Optos, ORA, and Pfizer. Dr. Rosenfeld has financial interests with Acucela, Boehringer Ingelheim, Canon, Carl Zeiss Meditec, Chengdu Kanghong Biotech, Oraya, Sucampo, Thrombogenics, Advanced Cell Technology, Alexion, and GlaxoSmithKline. Saturday, Nov. 10, 2012 MIGS can be performed by other subspecialties New options for minimally invasive glaucoma surgery (MIGS) are expanding the surgical treatment regimen, offering other ophthalmologists, specifically cornea specialists, the chance to perform the procedures, a glaucoma specialist said at Cornea Day, in conjunction with the Cornea Society. ���The answer is yes, certainly, you all are innovators, and these procedures are easy enough for cornea specialists to perform, but the glaucoma patient will still re- quire close surveillance,��� said Leon W. Herndon, M.D., Durham, N.C. Dr. Herndon presented an overview of MIGS procedures, including the Trabectome (NeoMedix, Tustin, Calif.) and the iStent (Glaukos, Laguna Hills, Calif.), both of which are approved for use in the U.S., and the Hydrus Intracanalicular Implant (Ivantis, Irvine, Calif.), which is not approved in the U.S. but is in a U.S. FDA investigational device clinical trial. Dr. Herndon said physicians who want to perform MIGS should know how to perform intraoperative gonioscopy. ���Although trabeculectomy remains the gold standard for incisional glaucoma surgery, the search for a procedure that can effectively and safely lower intraocular pressure and improve on these standards continues,��� he said. ���The majority of the novel procedures seek to avoid bleb formation and rely on augmentation of the physiologic outflow pathways. Certainly, randomized trials are needed.��� Editors��� note: Dr. Herndon has no financial interests related to his comments. ���Careful, honest, ethical��� approach needed to perform new surgical techniques Ophthalmologists need to prepare with care when learning a new technique to be ethically, legally, and medically ready to perform it for the first time. ���A careful, honest, and ethical approach will distinguish the competent ophthalmologist as he or she learns a new technique,��� said Roberto Pineda II, M.D., Boston. ���The foregoing suggestions will help place the patient first, minimize the risk of complications, and allow the ophthalmologist to gain technical expertise with confidence.��� The American Academy of Ophthalmology has applicable rules of ethics on the subject, he said, with the first rule being competence, wherein an ophthalmologist must have specific training or experience EW MEETING REPORTER 53 to perform the procedure in question or be assisted by someone who has. The second rule is informed consent. Dr. Pineda said medical legal issues include whether physicians are covered by malpractice insurance for the new surgical technique, whether they should tell a patient if it is their first case, and if the consent process should be supplemented. When preparing for the first case, physicians should have all necessary equipment and material at hand, consider being proctored, choose an easy case, have a rehearsal, avoid any time pressure, and prepare for any potential complications, according to Dr. Pineda. Editors��� note: Dr. Pineda has no financial interests related to his comments. Lens issues, complications dominate Refractive Subspecialty Day In a point-counterpoint discussion session, leading refractive surgeons offered their perspectives on everything from astigmatic correction to premium IOLs. Louis D. ���Skip��� Nichamin, M.D., Brookville, Pa., started off the session by noting, ���I am able to safely and reproducibly correct up to 3 D of astigmatism through the use of limbal relaxing incisions [LRIs]��� based on a patient���s age. At levels higher than that, he prefers to combine the use of toric IOLs with LRIs. ���I believe we will all become increasingly dependent upon the excimer laser to reduce residual astigmatism following ���successful��� implant surgery,��� he said. While surgeons are currently working on leaving patients with no more than 0.75 D of cylinder, ���my prediction is that the bar will soon be raised to a level of 0.25 D, for both sphere and cylinder,��� Dr. Nichamin said. Albeit uncommon, inadequate capsular support can be a potential complication of cataract surgery, and the best approach is to suture a posterior chamber IOL, said Walter J. Stark, M.D., Baltimore. He

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