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58 EW MEETING REPORTER Reporting live from the 2013 American Academy of Ophthalmology Annual Meeting in New Orleans December 2013 factor for glaucoma. "There have been several studies in the glaucoma literature that have reported that intraocular pressure variability is an independent risk factor for glaucoma," she said. "However it makes biological sense that intraocular pressure variability is another way of getting glaucomatous damage, and it's not just the intraocular pressure average over time," she said. Meanwhile, Anders Heijl, MD, Sweden, argued, "IOP variability is greater in glaucoma, and proportional to the IOP level," but the issue is whether IOP variability is an independent risk factor once the IOP level has already been taken into account. "Many of the studies that are frequently cited in support are flawed," he said. There is no evidence of IOP variability as an independent risk factor, he said, even though fluctuation is higher in eyes with a high mean IOP. Editors' note: Dr. Coleman has financial interests with AHRQ and the National Eye Institute. Dr. Heijl has financial interests with Alcon, Allergan, and Carl Zeiss Meditec. Treating keratoconus Swept-source optical coherence tomography (OCT) is "something to keep your eye on. The future of technology is here with this tool," said Stephen D. Klyce, PhD, New York, during a session on past, present, and future treatments for keratoconus. Placido and grid technologies had a high sensitivity, but slit scan was not quite as sensitive, he said. Dr. Klyce also recommends using the ANSI standard scale for ectasia. "When it comes to keratoconus, you should always evaluate topographic patterns as standalone first; if those are abnormal, then bring in other diagnostic tools," he said. Sagittal depth is the key to lens fittings for keratoconus, said Peter R. Kastl, MD, New Orleans. When fitting patients, lenses should be lined up from flattest to steepest, he suggested. In an analysis of studies on the topic, there is "an almost 100% success with contact lens fittings," Dr. Kastl said. "So even though there are other options available, these still work; they're safe and effective." Similarly, penetrating keratoplasty is a reasonable treatment for keratoconus, with an Australian study showing 86% are 20/40 or better after PK, and 28% needing contact lenses. "A study from Michigan showed 92% were 20/40 after 10 years, and 80% were 20/40 after 20 years," said Sanjay Patel, MBBS, Rochester, N.Y. But rejection remains an issue after full-thickness; glaucoma rates are rather low at about 5% after a mean follow-up of 14 years. Deep anterior lamellar keratoplasty (DALK) and endothelial keratoplasty (EK) each target a specific area of the cornea, while PK targets the whole cornea. "Don't remove donor Descemet's until you're sure there is no need to convert to a full thickness surgery," said Sadeer Hannush, MD, Philadelphia. When comparing DALK to PK, the latter "has a slight advantage in the initial postop time frame, but DALK improves with time," said Sheraz Daya, MD, London. When doing procedures that require a big bubble technique, "if you can't get the bubble even after several tries, use a modified Melles technique." Dr. Daya has had "some promising results" performing DALK after PK, he added. One of the issues surrounding studies on keratoconus is how progression is being defined, said Penny Asbell, MD, New York. "Keratoconus has a complex natural history; the majority of patients remain stable, but up to 15% may progress," according to results from a small study at her university. Corneal crosslinking has proven useful in keratoconus; in cases of infectious keratitis, "it stiffens the cornea, but we only have case reports to date," which is not sufficient to proclaim success. "In general, there are still a lot of outstanding questions surrounding crosslinking," she said. Editors' note: None of the physicians had financial interests related to their presentations. Medicare update highlights changes, regulations Physicians need to be aware of upcoming Medicare requirements and changes, including how they can avoid paying penalties, according to a comprehensive discussion focusing on issues and concerns. Jacob Reider, MD, acting national coordinator for Health Information Technology, Office of the National Coordinator/HHS, Washington, D.C., delivered the keynote address at the 2014 Medicare Forum. He discussed the criteria for Medicare and Medicaid EHR Incentive Programs and meaningful use. Stage 2 needs to be implemented by October 2014 or physicians will face a penalty, he said. He outlined how there are 16 meaningful use data elements, some of which do not pertain to ophthalmologists because of scope of practice issues. "So there are these 16 data elements, which are very ex-