This Week in Ophthalmology: Week of November 25, 2024

Editor's note: The below transcript has been lightly edited for clarity.

Hello, I am David Hutton of Ophthalmology Times. Welcome to another episode of This Week in Ophthalmology, a program looking at some of the week’s top headlines.

We have a special episode this week, looking at some more highlights from the American Academy of Ophthalmology meeting last month. I continue to go through the interviews we did at the event, and we will revisit a few during today’s Program.

Dr. John Josephson, from the Eye Specialists and Surgeons of Northern Virginia, shared insights on office-based surgeries and how it allows for the addition of new technologies and new procedures

John Josephson, MD: Hi. My name is John Josephson from Eye Specialists and Surgeons of Northern Virginia. We're in Fairfax. Really excited to be at the Academy meeting this year where we're talking a lot about office space surgery. We've been doing office space surgery since 2022 we've done over 1500 cases. What's really exciting is that we've been able to now offer new technologies, bring new things to our area, because we control the place where we do the surgeries. So we brought in bilateral surgeries for cataract and for refractive lens exchange. We've been able to do new cornea procedures. So we were the first in our area to bring SeaTac, which is cornea tissue addition keratoplasty, which has been an exciting technology where we're able to take patients with keratoconus and improve their topographies by 6 to 10 and even more, diopters, we're able to improve their uncorrected and corrected visual outcomes.

So just bringing all this new technology, because we have everything at the forefront within our office. Has this been a dream come true? So, you know, in an office based surgical suite, the surgery is the same. We're still performing the same procedure. They're less sedation, which actually, in my opinion, is a positive … patients aren't overly sedated, unresponsive, unable to help you look to the direction that you want them to be in. Patient Experience is a whole different ballgame. Patients are comfortable. They are able to come to the surgery. They don't have to be NPO. They don't have to get extensive testing beforehand. So, they have this premium experience where they're coming in for an experience just like LASIK surgery or some of the other procedures that we do in our office.

So, it just changes the whole ballgame. It takes it away from being a scary surgical procedure to having an office-based procedure. So patient eligibility is a question that we're often asked about office space surgery. The criteria has kind of shifted over time. Initially we were very selective. Patients had to be a certain type of surgery, age health. Now that we've become more comfortable with the procedure, patients with a little bit more complexities in their eyes, you know, some floppy, floppy iris or more dense cataracts, we're comfortable doing, you know, we still want to make sure that their health is good. So, a lot of patients will still get hmps or EKGs to make sure that they are healthy and appropriate for surgery. Obviously, any instability in their health, we're still going to take them to a surgical center. But for the most part, patients will choose where they want to have surgery, rather than us choosing it for them. And most patients will choose to have their surgery done in the office.

David Hutton: Dr. Nathan Radcliffe shared insights from his presentation at the annual Academy meeting titled, "Early cataract extraction for angle closure glaucoma."

Nathan Radcliffe, MD: Hello, this is Nathan Radcliffe, cataract and glaucoma specialist from New York City. I practice at New York Ophthalmology, the New York Eye Surgery Center, and I'm affiliated with Mount Sinai School of Medicine. Why you should consider early cataract extraction for patients with angle closure, elevated pressures, or angle closure glaucoma. And there are actually a few good studies on this topic. But I'd like to start with the alternative to taking the cataract out, which is to use a laser iridotomy and place a patient on medications. The data for laser iridotomy isn't that strong. This was looked at in a study called the ZAP study, which was a prospective study where patients had iridotomy in 1 eye or cataract in the other. There weren't a lot of people that benefited from the laser. And in fact, you needed to treat almost 50 patients in order to benefit 1 patient, in terms of the study's outcomes.

There are no approved IOP lowering medications for angle closure glaucoma. We're you using them all off label. Cataract surgery was studied in a trial called the EAGLE, prospective, multicenter randomized trial comparing laser iridotomy and meds to cataract surgery, and a cataract group did very well. Their angles were more open. They had a higher quality of life, and they either used fewer medications or had lower intraocular pressures, and in a long-term, different design, but similar study, these patients went on to have better outcomes with long-term lower medication use, up to 10 years, and even fewer cases of lost vision. So why does cataract surgery work so well? Well because it relieves relative pupillary block. It opens up the angle. It even relaxes the ciliary body.

So, if you have plateau with angle closure, it should help there, and it opens up the trabecular meshwork face by relaxing the scleral spur. So, in summary, I think the data is very clear. This is a good way to treat patients, I would say, who either have nerve damage or on pressure lowering medications with angle closure and so cataract surgery should be considered. One of the unique indications for patients with angle closure to undergo cataract surgery is if they have optic nerve damage with angle closure, or are on a number of medications. Interestingly, what isn't really necessary for the cataract extraction to be beneficial is for that cataract to be visually significant. Now, some insurances, some insurance companies, may quibble over this, but the data from the EAGLE study and the patient benefit is there, even if the cataract is not visually significant with angle closure, it's still medically significant and beneficial to remove it. When patients with angle closure undergo early cataract extraction, the benefits are essentially a disease modification, opening of their angle and either lowering the pressure or reducing the number of medications.

There are risks to cataract surgery. Most experienced surgeons find those risks to be less than 1 percent, but they include things like need for second surgery, inflammation, and in rare cases, glaucoma can result from cataract surgery, although the bulk of patients experience a glaucoma benefit. In a 10-year study comparing patients who received iridotomy to patients who received cataract surgery, the patients who received the cataract surgery did better, they needed fewer medications, and they had fewer cases of severe vision loss. But what's most interesting is the patients who underwent the iridotomy, in other words, who tried to avoid the early cataract surgery, over 10 years, 76 percent or so of them had their cataract out anyway. So, the reality is, the cataract is coming out. It's just that removing it earlier is going to give that patient a longer period of benefit to their vision and to their glaucoma status.

David Hutton: George O. Waring, IV, MD, provides insights from an on-demand poster as part of the annual American Academy of Ophthalmology taking place in Chicago, Illinois. This poster was titled, "Two-Year Clinical Feasibility Trial Outcomes for a Dual-Optic IOL System for the Treatment of Presbyopia and Cataract."

George O. Waring, IV, MD: Hi, it's George Waring IV, from the Waring Vision Institute in Mount, Pleasant, South Carolina, and it's my pleasure to discuss something really exciting here at the American Academy of Ophthalmology in Chicago. It's been a jam packed meeting, lot of extraordinary innovations in the pipeline, and one of the ones we're most excited about is modular accommodative IOLs. And we had the really wonderful opportunity to present on the OmniVu, modular lens system by Atia Vision.

We presented the 24-month results, which is really exciting to start to get some long-term data on how this next generation of accommodating lenses are performing. And what we found was that we had an excellent safety and efficacy profile. These lenses are maintaining stability, refractive stability, over 24 months within a 1/2 diopter. And I think that's one of the really exciting things about this lens. This is a more physiologic lens. This is a two-piece system with a modular, exchangeable anterior optic and a fluid-filled, shape-changing base that provides accommodation. So this does a few things for us. It allows for adjustability over time, which is really exciting. It also creates a potential space for us for things like drug illusion or even virtual reality. Everything's on the table for the future. But I think most importantly, and most immediately, it's a more physiologic lens, as I mentioned, this maintains the natural capsule in a capsule filling way. Well, what does that mean? We believe that this can have some real benefits to promote effective lens position over time, and we really believe that this bore out in our 2-year data.

When we look at the uncorrected binocular visual acuity outcomes, uncorrected distance acuity binocular was 20/16 intermediate 20/20, and near J1 and that's really exciting because, again, it promotes this idea of a full continuous range with, what we found to be, over four and a half diopters into focus at the 20/32, level, with really a natural range and also excellent quality of vision. So these are monofocal-like quality. It's a monofocal optic, but with the performance of an extended range, full vision range, actually, and that's amazing. So we marry the effective lens position opportunity with a continuous range with a high quality vision. Our results looking at, in a non-comparative way, the contrast sensitivity also behaves in a monofocal-like state. So ladies and gentlemen, we're really excited about this data, 2-year long-term data. We were very thankful to get to present it, and we're real optimistic about what the future holds with this technology.

David Hutton: Thank you for joining me for another episode of This Week in Ophthalmology. Be sure to look for more details on these and other great articles on our website, ophthalmologytimes.com.