Eyeworld

91 December 2017 EW MEETING REPORTER improving drop instillation. Patients should be re-evaluated to see how they're doing with drop instillation. If there is no improvement, she suggested considering alternatives like changing the bottle type, con- sidering laser treatment, or offering a drop aid. Dr. Wiggs began her lecture by stressing that a goal of glaucoma genetics research is to identify genes that code for proteins or define biological pathways that could be targets of novel therapies. Over the last 5–10 years, there has been a lot of progress in identifying genes that contribute to glaucoma. "When we think about glauco- ma genetics, it's helping to divide it into early onset forms and adult onset forms," she said. Genetically, the early onset forms are caused by rare mutations that have very large effects. These mutations and genes tend to run in families, Dr. Wiggs said. "In contrast, the variants that contribute to adult onset diseases are common," she said. In combination with environmental risk factors, they reach disease threshold. One reason that early onset diseases have such large effects is be- cause generally they disrupt protein function, Dr. Wiggs said. Despite recent advances, Dr. Wiggs said there is still a lot of work to do in glaucoma genetics and many genes to find. "We also have to understand more about how these genes contribute to disease," she said. Editors' note: Dr. Wiggs receives grant support from the National Eye Insti- tute (NEI). Dr. Bhorade has financial interests with Allergan and receives grant support from the NEI. Dr. Desai has no financial interests related to her presentation. Best retina papers Seven of the best retina papers from all of the retina societies' 2017 meet- ings—those of the American Society of Retina Specialists, Macula Society, Retina Society, and the American Uveitis Society—were compiled into one symposium. well to taking their medications," she said. Patient non-adherence to glaucoma medications ranges from 30–80%, and poor adherence can be associated with progression. Dr. Bhorade highlighted several barri- ers to patient adherence, the first of which is patient forgetfulness. Another barrier is difficulty instilling medication, which can be caused by poor dexterity, poor vision, or poor self-awareness. Other barri- ers are that patients don't think the medications help; patients get confused with medications; patients stop their drops due to side effects; patients are not using their drops at the proper time; patients run out of medications before insurance covers a refill; and patients can't afford medications. Dr. Bhorade discussed several other challenges as well: Glaucoma medications don't target trabecu- lar meshwork outflow; glaucoma can progress despite low IOPs; and healthcare coverage can pose prob- lems if the doctors can only pre- scribe what is covered by patients' insurance. To beat some of these challeng- es, Dr. Bhorade stressed educating patients on glaucoma and medica- tions, having aids to improve med- ication administration and adher- ence, potentially using non-patient dependent drug delivery systems, and having IOP-independent thera- py to reduce glaucoma progression. Manishi Desai, MD, Boston, presented "Innovative Approaches to Improve Eye Drop Instillation and Compliance." There are a number of problems with eye drop instilla- tion: missing the eye, squeezing too much, or touching the eye. Multiple studies show that patients are not as accurate as they perceive, Dr. Desai said, and physicians cannot predict who will be successful with drops. She shared a number of technol- ogies that can be used by patients to aid in putting in their drops. These include adapters to help direct the drops, aids for placement of drops, and modified droppers. Dr. Desai said doctors need to observe patients placing the drops and need to educate patients on Manus Kraff, MD, Chicago, de- scribed Dr. Kelman as extremely innovative. Dr. Kelman got the idea for phaco while sitting in the dentist's chair and examining the ultrasonic device used to clean his teeth. "He went back to his office and phaco was born," Dr. Kraff said. However, Dr. Kelman initially received a chilly reception in oph- thalmology, and he had to take his message directly to the public via talk shows. Still, ophthalmologists in the trenches loved him, Dr. Kraff said. Phacoemulsification did not take off until the 1980s. Similarly, Harold Ridley, MD, the inventor of IOLs, faced skepti- cism and did not get his due credit until much later, said Randall Ol- son, MD, Salt Lake City. Robert Osher, MD, Cincinnati, presented a video series that credited a variety of pioneers within cataract surgery. Among the techniques and surgeons he credited were Robert Sinskey, MD, for one-handed phaco, Richard Kratz, MD, for bimanual phaco, and Dr. Kelman. Editors' note: Drs. Kraff, Olson, and Osher have no financial interests relat- ed to their presentations. Development of new anti- glaucoma medications and drug delivery systems A symposium focusing on glaucoma also included the Shaffer Lecture, which was given by Janey Wiggs, MD, PhD, Boston, on "Glaucoma Genes and New Opportunities for Therapy." During the session, Anjali Bhorade, MD, St. Louis, presented "Beating the Challenges in Medical Glaucoma Therapy." Topical ocular hypotensive agents are the first line treatment for the majority of glau- coma patients in developed nations, she said. However, despite treat- ment, glaucoma can still progress, and there are a number of challeng- es to overcome in order to improve glaucoma medical therapy. The first challenge that Dr. Bhorade discussed was patient adherence. "We've known for decades that patients do not adhere mimics dry eye and has symptoms that include irritation, burning, and dryness. Although there is still much to learn about optimal treatment for neurotrophic pain in dry eye, oph- thalmologists are using lubricants, anti-inflammatories, goggles, scleral lenses, environmental changes, and oral gabapentin for central pain. Topical anesthesia and scleral lenses are treatments for peripheral neuro- trophic pain. Victor Perez, MD, Durham, North Carolina, presented informa- tion on the four anti-inflammatory treatment categories for dry eye, including steroids, T-cell inhibitors, anti-integrins, and biologics. Phar- maceutical companies are develop- ing "smart" steroids so that dos- ages are lower and more effective, he explained. One advancement for T-cell inhibitors has been the introduction of Restasis MultiDose (cyclosporine, Allergan, Dublin, Ire- land). Within anti-integrin therapy, lifitegrast (Xiidra, Shire, Lexington, Massachusetts) has recently entered the market. Other therapies men- tioned by Dr. Perez were autologous serum and platelet rich plasma, the latter of which Dr. Perez described as a "personal approach" therapy. The session was held in conjunc- tion with the American Academy of Optometry. Editors' note: Drs. Begley and Caffery have no financial interests related to the presentation. Dr. Perez has finan- cial interests with Allergan, EyeGate Pharmaceuticals (Waltham, Massa- chusetts), Shire, and other ophthalmic companies. Cataract surgery has lively, controversial history From the discomfort of couching to the shock waves caused by IOLs and phacoemulsification, the history of cataract surgery has been anything but dull, said presenters at a session on the topic. Although numerous advancements for cataract surgery were discussed during the session, there was a broad focus on Charles Kelman, MD, the father of phaco. Phacoemulsification celebrates its 50th year anniversary this year. continued on page 96

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