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20
14
m ed i a k i t
The Trusted Source for Clinical Insights
The Trusted Source for Clinical Insights
JANUARY 2013
WHEN TO SUSPECT
SIMPLEX
Spot & Treat
Ocular HSV
Gunshot Wounds
in the E.R.
Statins & the Eye
A Look at the Latest Data
Rescuing the Retina
Advances in Stem Cell Research
BURGLARY!
How to Survive a
HIPAA Nightmare
EyeNet is the Academy’s official newsmagazine and
News in Review
the premier source among the ophthalmic trade press
comme n ta r y a nd p e r sp e c t i v e s
of credible information for ophthalmologists. EyeNet
Statin-AMD Finding
Is Unexpected
delivers practical clinical information that
A
study that set out to find evidence that statins
may help prevent age-related macular degen-
can be applied immediately in patient care, plus
eration (AMD) yielded a surprise finding. One
subset of patients—those with consistently
high serum low-density
lipoprotein (LDL) or serum
triglyceride (TG) levels despite a year or more of statin
use—had an increased risk
of developing wet AMD.1
Statins, the most commonly prescribed drugs in
the United States, are used
to treat underlying pathologic processes that lead to
heart disease. Those same
processes are thought to
play a role in the development of AMD, so a team
of researchers, led by Brian
L. VanderBeek, MD, MPH,
theorized that statins might
confer a protective effect
in the eye. He is assistant
professor of ophthalmology,
ophthalmologists, including business and news
b r i a n l . va n d e r b e e k , m d , m p h
coverage of a broad range of subjects of interest to
—all in a concise, highly readable format.
retina and vitreous service,
Scheie Eye Institute, University of Pennsylvania.
The researchers asked
two main questions. First:
Is statin use associated with
the development of nonexudative AMD? They found
that it is not.
And second: Is statin use
associated with the development of exudative AMD?
The answer to that is more
nuanced. “There is potentially a subset of individuals
who, despite taking statins
regularly, continue to have
elevated cholesterol levels;
and these individuals may
have an elevated hazard for
developing exudative AMD,”
WET AMD. Patients on statins for a year or more but who
continued to have high LDL and triglyceride levels appeared
to be at increased risk for wet AMD.
said Dr. VanderBeek.
The study reviewed records of more than 100,000
beneficiaries from a national insurance claims database
for the years 2001 through
2007. About half of the patients used statins. All were
age 60 and older, had been
enrolled in the database for
two or more years, and had
visited an eye care provider
at least once in two years.
Only those who had baseline laboratory values for
LDL, HDL, and TG were included because statins alter
levels of those serum lipids.
The researchers created
three models from the pool
of beneficiaries. Statins and
lipid values were treated as
independent variables in all
models. In the first model,
“development of nonexudative AMD,” individuals had
no diagnosis of any AMD
in the first two years in the
plan (n = 107,007). In the
second model, “development of exudative AMD,”
individuals had no previous
diagnosis of wet AMD in the
first two years of the plan
(n = 113,111). In the third,
“progression from nonexudative AMD to exudative
AMD,” individuals had no
e y e n e t
21
Clinical Update
RETINA
Radiation for CNV:
Back to the Future
Organization Affiliation
EyeNet is a member benefit for American Academy of Ophthal-
by linda roach, contributing writer
interviewing timothy l. jackson, phd, frcophth, pravin u. dugel, md,
donald s. fong, md, mph, and reid f. schindler, md
mology (AAO) Members and Members in Training worldwide.
It also is a benefit for American Academy of Ophthalmic
Executives (AAOE) Members.
T
D u g e l P U e t a l . O p h t h a l m o l o g y. 2 012 N o v. 19 [ E p u b a h e a d o f p r i n t ]
AAO membership includes 93% of practicing U.S.
ophthalmologists.
AAOE membership includes approximately 6,000 office
administrators, managers, and physicians.
he dream of using radiation
to treat the wet form of agerelated macular degeneration (AMD) is back. And,
just as before, beginning
with studies in the 1990s, a blast of
early enthusiasm is being tempered by
the painstaking process of attempting to prove clinical efficacy. This
time around, though, no one is asking
radiation to conquer choroidal neovascularization (CNV) solo.
Instead, researchers are asking
whether ionizing radiation might work
synergistically with intravitreal antiVEGF drugs to reduce the personal,
financial, and social burdens of treating AMD. They want to know if a primary or secondary radiation treatment
might dry up CNV lesions faster, preserve visual acuity, and extend the intervals between intravitreal injections.
Early results of small uncontrolled
studies seemed promising, but reports
from two large randomized controlled
clinical trials in the last year brought
mixed results.
Radia t i o n Z o n e s
Schematic drawing depicts the amount of beta radiation delivered based on distance from the endoscopic probe used in epimacular brachytherapy. The point
directly under the probe receives a dose of 24 Gy.
lost fewer than 15 EDTRS letters of
visual acuity over the 24-month follow-up period, compared with 90 percent in the controls, the investigators
reported last November.1
“After two years of follow-up, the
safety profile appears acceptable. But
we can’t recommend this as a primary
form of treatment for CNV,” said lead
author and coinvestigator Pravin U.
Dugel, MD, managing partner at Retinal Consultants of Arizona, in Phoenix. “Regardless of the encouraging
results in the smaller studies, you have
to go by the science. The bottom line
Recent Clinical Trial Results
CABERNET. The results were disappointing in the two-year follow-up
report from CABERNET, a trial of
epimacular brachytherapy. The study
compared outcomes in treatmentnaive patients who received localized
beta radiation of 24 gray (Gy) plus
anti-VEGF injections against outcomes
in an injections-only control group.
The study found that 77 percent of
subjects in the radiation-treated group
is that the CABERNET study did not
meet its primary endpoint.”
INTREPID. At the Academy’s 2012
Joint Meeting in Chicago, Timothy L.
Jackson, PhD, FRCOphth, reported
positive results from the European INTREPID trial of an x-ray–based treatment, stereotactic radiotherapy.2 The
study found that previously treated
AMD patients whose maculae received
16- or 24-Gy radiation doses at the
start of the study required 30 to 35 percent fewer as-needed (PRN) injections
of ranibizumab in the 12 subsequent
months than did the sham-treated
35
e y e n e t
Destination New Orleans
get ready for the annual meeting
Issuance
frequency: 12 times a year
Beat the CloCk
n Register by aug. 7; Many
issue date: First of the month
MAILING DATE & CLASS: 25th of the preceding month, second class
Fees Will Increase on aug. 8
Registration is now open for Academy
and AAOE members. Registration for
nonmembers opens on July 10.
Register by Aug. 7, and you will save
money as well as having your badge
and materials mailed to you. After
Aug. 7, there will be an increase in
many fees, including Subspecialty Day
registration, the Academy Plus course
pass, and Annual Meeting nonmember registration.
For more information, visit www.
aao.org/registration.
n Book early to Get Your First
AVERAGE CIRCULATION: 22,000 (see page 10 for details)
ACCEPTANCE AND COPY RESTRICTIONS: Subject to approval by the
Academy
2 2014 e y e n e t
media
kit
PLACEMENT POLICY: Interspersed
Choice of Flight and hotel
noc&vb
Advertising
part t wo of six
n FIVE DAYS IN NEW ORLEANS. Join your colleagues for seven Subspecialty Day
meetings, two coding meetings, and the Academy’s 117th Annual Meeting.
Nov. 15-16—Subspecialty Day: Take your pick of seven meetings. Explore five
one-day programs and a pair of two-day programs.
• Cornea 2013: Through the Looking Glass—Where We Are, Where We’re Headed (Nov. 16)
• Glaucoma 2013: The Future Is Now! #Glaucoma2013 (Nov. 16)
• Neuro-Ophthalmology 2013: What to Make of This? Recognizing the Distinctive Neuro-Ophthalmic Symptom, Sign, or Test (Nov. 16)
• Oculofacial Plastic Surgery 2013: Blues, Blephs, and Blowouts (Nov. 16)
• Pediatric Ophthalmology 2013: Preparing for the Next Generation (Nov. 16)
• Refractive Surgery 2013: Perfecting Vision (Nov. 15-16)
• Retina 2013: Let the Good Times Roll (Nov. 15-16)
l Nov. 16—Coding: Register for two intensive meetings. In addition to the Annual Meeting’s practice management sessions (see page 72), there will be two
half-day meetings that require separate registration: AAOE Conquering ICD-10CM for Ophthalmology (8-11 a.m.) and AAOE Coding Camp (12:30-3:30 p.m.).
l Nov. 16-19—Annual Meeting: 10 reasons to register. Your registration includes
access to: 1) the 2013 exhibition, 2) Academy Café panels, 3) Learning Lounge
discussions, 4) original paper sessions, 5) scientific posters, 6) Spotlight sessions, 7) symposia, 8) Technology Pavilion presentations, and 9) the video program, plus 10) you’ll get a copy of the Annual Meeting Final Program.
l
Find information about travel, hotels,
and city transportation at www.aao.
org/hotels.
Flights and rental cars. Book your
air and car reservations through the
Academy’s official travel company,
Association Travel Concepts (ATC).
Agents are available 5:30 a.m.-4 p.m.
Pacific Time, Monday-Friday. Book
online at www.atcmeetings.com/aao
or by e-mail at reservations@atcmeet
ings.com.
Hotel reservations. Book your hotel
room through Expovision, the Academy’s official housing company. Agents
are available 8:30 a.m.-5:30 p.m. Eastern Time, Monday-Friday. Reach them
via www.aao.org/hotels or by e-mail at
[email protected].
Arriving from outside the United
States? International attendees should
check their visas and passports to en-
69
Beat the Clock
72
Hall Highlights
70
Program
sure documents are up to date. Visit
www.aao.org/visa for additional international travel information, plus links
e y e n e t
69
2013 Kantar Media Results
Reach and Visibility
EyeNet delivers unparalleled reach and visibility. We have
a loyal audience that reads the magazine regularly and
thoroughly. And visibility for your ad is virtually guaranteed,
as EyeNet has the #1 average page exposures rating in the
industry for the third year in a row.
RECEPTIVE READERS. Among ophthalmologists who are in the early
majority of drug adopters, EyeNet is #1 in three important rankings:
average issue readers, high readers, and average page exposures. Take
Morning Rounds
advantage of this positioning with a well-placed ad in EyeNet.
The Lawyer Who Couldn’t
Outrun Trouble
by jessica l. chen, md, and richard k. lee, md, phd
edited by steven j. gedde, md
DEDICATED READERS. Did you know that 48% of ophthalmologists
W
hen Cindy Gonzales* visited her optometrist, she anticipated
that it would just be a routine examination for eyeglasses. But
things took a turn for the worse when the optometrist found
that the 31-year-old attorney’s IOP was 28 mmHg in her right
eye and 26 mmHg in her left. He promptly referred Ms. Gonzales to our glaucoma clinic for further evaluation.
read every issue of EyeNet—and that more ophthalmologists read EyeNet
We Get a Look
Ms. Gonzales reported having a history of intermittent headaches and
blurred vision whenever she pursued
any vigorous activity, such as running.
She was not using eyedrops and had
not undergone any laser or surgical
treatment, and she denied having any
history of ocular trauma. Ms. Gonzales was otherwise healthy and not taking any systemic medications.
cover to cover than any other general interest ophthalmic trade publication? Advertise with the most popular newsmagazine in the industry!
W ha t ’s Yo ur D iag n o sis ?
B ascom Palmer Eye Ins t itu te
1
#1 in High Readers
When asked about her family
history, she noted that her paternal
grandmother was blind secondary
to glaucoma and that her maternal
grandfather and great-aunt both were
diagnosed with glaucoma late in life.
Upon examination, Ms. Gonzales’
BCVA was 20/20 in both eyes with a
refractive error of –2.50 D sphere in
her right eye and –3.00 D sphere in
her left. Her IOP was 22 mmHg in the
right eye and 23
mmHg in the
left. Both pupils were 3 mm, and they
were reactive and without an afferent
pupillary defect. Ocular movements
were full in both eyes. Her confrontation visual fields were full in both eyes.
Humphrey visual field testing was normal in both eyes.
The slit-lamp examination showed
clear corneas with prominent Krukenberg spindles (Fig. 1) and a deep anterior chamber in both eyes. Gonioscopy
revealed a peculiar iris contour that
bowed posteriorly as well as heavy pigmentation of the trabecular meshwork,
without any peripheral anterior synechiae. Her central corneal thickness
was 565 µm in both eyes, and midperipheral iris transillumination defects
in a spokelike pattern were present 360
degrees (Fig. 2). Her lenses were clear.
The dilated fundus exam revealed
optic nerves that appeared healthy,
2
(1) Prominent Krukenberg spindles were evident in both eyes at the slit lamp. (2) In addition, there were peripheral iris
transillumination defects in a spokelike pattern in both eyes.
47
e y e n e t
EyeNet has the most avid readers for the fifth year in a row.
Keeping Up With
Evolving Therapies
Diabetic
Diabetic retinal
retinal Disease
Disease
40% EyeNet
38% Publication A
37% Publication B
b y annie st uart, con t ribu t ing w ri t e r
For many years, laser was the treatment mainstay for diabetic
retinal disease, and some thought corticosteroids held great
promise. But, today, anti-VEGF therapies are taking the field by
storm, while research continues on novel options and combinations of old standbys. Learn how you can incorporate these new
approaches into your practice.
36% Publication C
N
early 26 million Americans have
diabetes, and another 79 million
have prediabetes.1 Many are unaware of their condition and the
risk it poses to their vision: Diabetic retinopathy is the leading cause of new
blindness in Americans aged 25 to 74.1
Fueled by factors such as sedentary lifestyles
and increased consumption of sugary, high-fat
foods, the rising rate of diabetes, particularly
among today’s youth, is a major global concern,
said Abdhish R. Bhavsar, MD, managing partner
and director of clinical research at the Retina
Center of Minnesota and attending surgeon at
Phillips Eye Institute, in Minneapolis. “I’m concerned about what this will mean 10, 20, or 30
years from now. These younger generations may
experience diabetic retinopathy at an earlier age.
But I’m also hopeful that public education programs on healthier lifestyles will help reduce the
rates of diabetes and associated eye disease.”
Ophthalmologists have other reasons to be
hopeful as well: better tools and strategies than
ever before for managing and monitoring the ret-
a l f r e d t. k a m a j i a n
27% Publication D
40% EyeNet
24% Publication E
38% Publication A
24% Publication
37% FPublication B
36% source:
Publication
C 2013 Eyecare Readership Study, Table 801.
Kantar Media,
46
m a y
inal complications of diabetes. Anti-VEGF agents,
laser, steroids, surgery, and even systemic therapies are all contributing to the ongoing evolution
in treatment for diabetic eye disease.
The Power of Diabetes Management
Despite the growing epidemic of diabetes, Carl D.
Regillo, MD, sees a silver lining. Better systemic
diabetes care, he said, can stave off progression of
retinopathy for a longer period of time. He offers
some anecdotal evidence—a reduction in the
numbers of problems related to diabetic retinopathy that he sees in his patients.
“Ten or 15 years ago, the average person with
diabetes who came to see me either didn’t know
their A1c or they quoted levels that were so high,
I cringed,” he said, referring to the glycated
hemoglobin test that helps monitor blood sugar
levels. “Nowadays, I much more commonly see A1c
levels that are fantastic.”
2 0 1 3
e y e n e t
47
27% Publication
D
43% EyeNet
Publication A
c a r o ly n b l a c k , n o r t h b e nd m e d i c a l c e n t e r , c o o s b ay, o r e .
Blink
More ophthalmologists
likely
see a page
24% are
Publication
Fto Publication
40%
B in EyeNet than other
ophthalmic publications for the38%
third
year
in
a
Publication C row.
32% Publication D
43% EyeNet
29% Publication E
43% Publication A
28% Publication
F
40% Publication
B
0
What is this month’s mystery condition? Find the answer in the next issue, or post your comments online now at www.eyenet.org.
LAST MONTH’S BLINK
Metastatic Cutaneous
Melanoma to the Choroid
A
68-year-old woman presented with blurry vision in the
left eye, a condition that she had noticed for three
weeks. Three years prior, she had undergone wide excision of cutaneous melanoma 13 mm in depth on her left forearm. At that time, 10 left axillary sentinel lymph nodes were
biopsied and were found to be negative.
On ocular examination, her visual acuity was 20/20 in the
right eye and 20/70 in the left eye. A dilated fundus exam of
her left eye revealed a pigmented choroidal mass along the superotemporal arcade, with orange pigment and subretinal
fluid extending into the fovea. The mass measured 3.2 mm
in apical height with a basal diameter of 9.0 mm x 10.6 mm
by ultrasonography. The A-scan demonstrated high internal
reflectivity.
Given the patient’s history of cutaneous melanoma, a PET
scan was performed, which revealed multiple lesions in the
38% Publication C
32% Publication D
29% Publication E
58
s e p t e m b e r
Bob Myles, Emory University, Atlanta
lungs and a 4-cm lesion in the liver consistent with metastatic
disease. The choroidal lesion was presumed to be metastatic in
nature and the patient was referred to oncology. A lung biopsy
was performed, which confirmed metastatic melanoma.
Written by Jill R. Wells, MD, and Chris S. Bergstrom, MD, Emory
University, Atlanta.
photo credit
#1 in Average Page
Exposures
24% Publication
E
43%
2 0 1 3
28% Publication F
source: Kantar
Media, 2013 Eyecare Readership Study, Table 701.
www
.eyenet.org/advertise 3
2014 EYENET EDITORIAL BOARD
Ophthalmic Pearls
OCULOPLASTICS
Waveofofthe
theFuture?
Future?
wave
Performing an Endoscopic
Conjunctivodacryocystorhinostomy
by j. javier servat, md, flora levin, md, francesca d. nesi-eloff, md, and
frank a. nesi, md, facs. edited by ingrid u. scott, md, mph, and sharon fekrat, md
j . j av i e r s e r vat, m d
Patient Selection
Examination. As with patients treated
with endoscopic dacryocystorhinostomy, all patients scheduled to be treated
with endoscopic CDCR should have
an intranasal examination in order
to evaluate the area of potential tube
placement.
Severe septal deviation, hypertrophic middle turbinates, and masses
should be evaluated and treated prior
to endoscopic CDCR. In addition,
a deviated nasal septum can make
endoscopic surgery difficult or impossible to perform. If not enough space
is available, a septoplasty will be required.
All patients should also have a
careful slit-lamp examination and an
evaluation of other causes of ocular
irritation. Special attention should be
paid to the conjunctiva and caruncular
area for signs of inflammation, symblepharon, or infection. A previously
placed medial tarsorrhaphy or any
abnormality of the eyelids secondary
to trauma or resection of tissue may
require correction prior to the placement of the CDCR tube.
Indications. Canalicular obstruction is an accepted indication for endoscopic CDCR. This may be caused
by trauma, surgery, systemic chemotherapeutic agents (such as fluorouracil or docetaxel), topical antiglaucoma
medications (including dorzolamide,
pilocarpine, and timolol), and antiviral drops (such as idoxuridine and
trifluridine).
When canalicular stenosis is present, silicone stenting can be attempted.
If the results are unsatisfactory, then
an endoscopic CDCR is indicated.
Uncommon indications include
severe lacrimal pump failure, which
may occur with Bell palsy and other
causes of facial paralysis, and tear
hypersecretion, as in cases of aberrant
regeneration.
Benefits
Advantages of endoscopic CDCR
over conventional CDCR include the
following: 1) minimal or no postoperative ecchymosis and edema; 2)
In a sea of new high-tech tools for ophthalmic surgery,
intraoperative wavefront aberrometry is an inno­
vation that some believe could enable cataract sur­
geons to send nearly all of their patients home with
less than 0.5 D of pseudophakic refractive error—
without breaking the bank.
Intraoperative aberrometry is intended to reduce
residual refractive error through aphakic refraction,
which allows the surgeon to confirm or revise the
IOL power choice reached via preoperative biom­
etry, optimize the lens location, and tailor arcuate
corneal incisions to the eye’s astigmatic needs.
“This is going to be the next horizon in oph­
thalmic surgery,” said Steven I. Rosenfeld, MD, a
cornea, refractive, and cataract surgeon in Delray
Beach, Fla.
Initially, intraoperative aberrometry was used
in eyes that had undergone refractive surgery,
which makes conventional biometry methods less
predictable, said Sonia H. Yoo, MD, at the Bascom
Palmer Eye Institute. But refractive cataract surgery
practices around the country that have adopted this
technique have found that it has increased the num­
ber of people with previously unoperated eyes who
choose a presbyopia­correcting or toric intraocular
lens (IOL). This trend may hint at what lies ahead.
“I could imagine a time when every single pa­
tient who undergoes lens surgery has intraoperative
aberrometry and refraction performed as a stan­
dard of care,” Dr. Yoo said. “You would take the
picture and, basically, get the IOL power without
having to put in a fudge factor or otherwise guess­
timating.”
1
2
3
early STePS. (1) A 12-gauge shielded intravenous catheter is bent approximately 30 to 45 degrees.
(2) The IV catheter is positioned
between the nasal septum and the
lateral nasal mucosa. (3) The metal
needle is removed, leaving only the
plastic sheath in position.
1 DevIce ApproveD, Another AwAIts
less surgical manipulation of medial
canthal tissues; 3) no skin scarring;
and 4) better placement and more accurate length selection of the Pyrex
tube. The lack of tissue manipulation
is particularly important in the healing
process, as it improves the chance that
a l f r e d t. k a m a j i a n
A
s originally described by
Lester Jones,1 conjunctivodacryocystorhinostomy
(CDCR) with the insertion
of a Pyrex tube changed
the management of canalicular obstruction. Before this development,
management options for proximal obstruction included canalicular stenting
with polyethylene tubes or reiterative
probing, both of which had poor success rates.
Initially, CDCR was performed as
an external procedure by way of a medial canthal incision with careful positioning of a Pyrex tube at the region
of the caruncle. Currently, endoscopicassisted techniques are used, resulting
in better positioning of the tube, shorter operating time, and less bleeding.2-3
This review will present an overview of patient selection, surgical
technique, and recommendations for
postoperative care.
38
e y e n e t
GLAUCOMA
Kenneth L. Cohen, MD
Bonnie A. Henderson, MD
Warren E. Hill, MD
Jason J. Jones, MD
Boris Malyugin, MD, PhD
Cathleen M. McCabe, MD
Kevin M. Miller, MD
Robert H. Osher, MD
Steven I. Rosenfeld, MD, FACS
Abhay R. Vasavada, MBBS
Sanjay G. Asrani, MD
Keith Barton, MD
Anne Louise Coleman, MD, PhD
Jonathan G. Crowston, MBBS, PhD
Steven J. Gedde, MD
Ivan Goldberg, MBBS
Jeffrey M. Liebmann, MD
Steven L. Mansberger, MD, MPH
Anthony D. Realini, MD
Angelo P. Tanna, MD
LOW VISION
Preston H. Blomquist, MD
Sherleen Huang Chen, MD
Robert B. Dinn, MD
Richard A. Harper, MD
Susan M. MacDonald, MD
Janet Y. Tsui, MD
Mary Lou Jackson, MD
Lylas G. Mogk, MD
NEURO-OPHTHALMOLOGY
CORNEA /EXTERNAL DISEASE
Helena Prior Filipe, MD
Robert F. Haverly, MD
Elizabeth M. Hofmeister, MD
Thomas J. Liesegang, MD
Mark J. Mannis, MD
Christopher J. Rapuano, MD
Sonal S. Tuli, MD
M. Tariq Bhatti, MD
Kimberly Cockerham, MD, FACS
Eric Eggenberger, DO
OPHTHALMIC ONCOLOGY
Zélia M. Corrêa, MD, PhD
Leah Levi, MD
Tatyana Milman, MD
Arun D. Singh, MD
OPHTHALMIC PATHOLOGY
Sander Dubovy, MD
Deepak Paul Edward, MD
4 2014 e y e n e t
media
kit
aberrometry
promises to finetune cataract
surgery results
through aphakic
refraction—
but is it making
a difference in
practice?
By LInda Roach, Contributing Writer
2 0 1 3
e y e n e t
39
43
CATARACT
COMPREHENSIVE
OPHTHALMOLOGY
s e p t e m b e r
The only intraoperative aberrometer currently
available in the United States is the Optiwave Re­
fractive Analysis (ORA) system (WaveTec), and a
Intraoperative
second­generation de­
vice is on the horizon.
Meanwhile, Clarity
Medical Systems hopes
to win FDA marketing
approval by the end
of 2013 for its Holos
intraoperative aberrom­
etry system for cataract
surgery. Both ORA and
Holos are designed to
be mounted on the op­
erating microscope and
function in effect as an
autorefractor.
Like the ORA, Holos
gathers optical wavefront
and refraction data to
verify the preplanned
IOL power and help the
surgeon choose the size
and location of incisions
to correct astigmatism.
According to David F.
Chang, MD, a Los Altos,
Calif., ophthalmologist who worked with the Holos
in its early days, the device uses a proprietary wave­
front­analysis method that is faster than the inter­
ferometry used by ORA, allowing it to “measure
and compute the wavefront refraction more rapidly.
“Holos is like viewing a video, while ORA is
more like viewing a snapshot,” Dr. Chang said.
“You could literally dial a toric IOL into alignment
according to an instantaneous display of the residu­
al cylinder axis and amount. You could immediate­
ly assess the effect of your phaco incision, of widen­
ing or deepening an LRI, of lifting the lid speculum,
or of over­ or underinflating the globe.”
OPHTHALMIC
PHOTOGRAPHY
Michael P. Kelly, FOPS
PEDIATRIC OPHTHALMOLOGY
Michael F. Chiang, MD
Jane C. Edmond, MD
David G. Hunter, MD, PhD
Christie L. Morse, MD
David A. Plager, MD
PLASTIC AND
RECONSTRUCTIVE SURGERY
George B. Bartley, MD
Evan H. Black, MD
Bita Esmaeli, MD
Andrew R. Harrison, MD
Bobby S. Korn, MD, PhD
REFRACTIVE SURGERY
Daniel S. Durrie, MD
Alaa El-Danasoury, MD
George D. Kymionis, MD, PhD
Yaron S. Rabinowitz, MD
J. Bradley Randleman, MD
Roger Steinert, MD
George O. Waring IV, MD
Sonia H. Yoo, MD
RETINA / VITREOUS
Kimberly A. Drenser, MD, PhD
Sharon Fekrat, MD
Donald S. Fong, MD
Mitchell Goff, MD
M. Gilbert Grand, MD
Julia A. Haller, MD
Nancy M. Holekamp, MD
Andreas K. Lauer, MD
Kgaogelo E. Legodi, MBChB
Jeffrey L. Marx, MD
Adrienne Williams Scott, MD
Ingrid U. Scott, MD, MPH
Gurav K. Shah, MD
Richard F. Spaide, MD
UVEITIS
James P. Dunn Jr., MD
Gary N. Holland, MD
H. Nida Sen, MD
2014 EDITORIAL CALENDAR: THE BEST IN CLINICAL INSIGHTS, 12 TIMES A YEAR
January
February
March
April
Update on HIV Ocular Disease
Current State of ROP Therapy
Spotlight on Cataract
Despite the notable success of highly
active antiretroviral therapy (HAART),
many people with HIV infection
continue to experience ocular
complications. Learn how HAART
has changed the course of HIV eye
disease and what this means for
clinical care today.
In recent years, the pendulum of
opinion has been swinging between
laser and anti-VEGF therapy for
retinopathy of prematurity. Pediatric
and retina specialists present the latest data and their approach to these
therapies, alone or in combination.
Revisiting the excitement from the
Spotlight on Cataract session during
last November’s Annual Meeting,
EyeNet presents a variety of surgical cases, along with audience poll
questions and answers, and expert
commentary about the survey results.
New Guidelines: Corneal
Opacification, Edema, Ectasia
clinical update
clinical update
clinical update
Cataract Glaucoma Retina
Comprehensive Oculoplastics
Cornea
distributed at woc / apao
May
Vitreomacular Interface
Abnormalities
How do the new evidence-based
practice guidelines from the
Academy affect your management
of opacities, edema, and ectasia?
A roundtable discussion highlights
the most significant points and their
clinical application.
Oncology Pediatrics Retina
clinical update
distributed at ascrs
Comprehensive Neuro Trauma
June
July
August
Dry Eye Mechanisms
and Medications
Optic Nerve Swelling:
Diagnostic Challenges
Managing Presbyopia
Controversy persists over the best
approach to managing adhesions,
traction, macular holes, and epiretinal membranes. What you need to
consider in choosing from the range
of options: pharmacolysis, standard
or small-gauge vitrectomy, or watchful waiting.
Will new findings in the pathogenesis
of dry eye translate into relief for
patients? Apart from ocular therapies
in development, researchers are finding surprising new uses for existing
nonophthalmic drugs. A look at the
most promising approaches.
With causes ranging from infectious
to vascular to malignant, the swollen
optic nerve is a crucial, but often
mystifying, sign. And the patient’s
vision or even life may depend on
your timely diagnosis. Expert advice
for sorting it out.
clinical update
clinical update
clinical update
Glaucoma Pediatrics Refractive
Comprehensive Oculoplastics
Retina
destination chicago
destination chicago
distributed at asrs
September
October
November
December
Systemic Causes of Intraocular
Inflammation
Annual Meeting Issue
Evolving AMD Therapies
Minimally Invasive Glaucoma
Surgery
OCT Roundup
Uveitis can be triggered by a staggering number of systemic diseases,
and their ocular manifestations
often appear similar. Learn the key
associations of anatomy, age, ethnicity, and nonocular signs symptoms to
unlock the diagnosis.
Although anti-VEGF agents remain
the go-to therapy for wet age-related
macular edema, concerns about
treatment burden and possible longterm side effects continue to mount.
New classes of agents and combined
therapies may be the answer.
clinical update
clinical update
How do you decide which patients
can benefit from new microstents
and other minimally invasive procedures—and what device is most
appropriate for a given individual?
Catch up on the devices now available, as well as those waiting in the
wings.
l
l
l
l
l
l
Cataract Glaucoma Pediatrics
l
l
destination chicago
Comprehensive Cornea
Oculoplastics
l
l
l
l
l
l
l
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Demographics continue to drive the
quest for presbyopia solutions—other
than spectacles. Presbyopia can
now be addressed with intraocular
lenses, corneal inlays, and surgical
procedures. Pros and cons of current
techniques, and a look ahead.
clinical update
Comprehensive Neuro Retina
l
Cornea Refractive Uveitis
destination chicago
destination chicago
distributed at escrs
l
l
clinical update
l
Your guide to recent developments
in optical coherence tomography: a
case-based approach using multiple
images to demonstrate the application of anterior and posterior segment OCT techniques to specific eye
diseases.
clinical update
Comprehensive International
Uveitis
l
l
Neuro Refractive Retina
l
l
destination chicago
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6 2014 e y e n e t
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AAO 2014 Opportunities
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cover advertising. It mails with the October issue, and distribution is also guaranteed to meeting attendees.
EyeNet “Best of” Collections. Each edition is a quick recap of the important discoveries,
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is distributed at the Spotlight on Cataract Surgery session. Each edition is open to single or
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original research as a sole advertiser.
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EyeNet
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From Meaningful Use to Boosting Productivity,
EHR Experts Share Their Tips
Year-Round Opportunities
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EyeNet Extra. These custom supplements written by the EyeNet team examine topics of
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can suggest topics, and welcomes your ideas.
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Paper and electronic reprints of EyeNet articles can be effective sales tools.
www
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CIRCULATION PROFILE
EyeNet Circulation Profile*
Active U.S. Academy Members. . . . . . . . . . . . . . . . . . . . . . . . . . . 16,740
U.S. Academy Members in Training. . . . . . . . . . . . . . . . . . . . . . . . 2,215
U.S. AAOE Members (nonphysician).. . . . . . . . . . . . . . . . . . . . . . . 3,446
Online only (International Members and...........................13,401
Members in Training)
PR ACTICE PERFECT
American Academy of Ophthalmology Members
CL INIC A L R E SE A RCH
Who Needs IRBs? A Primer on
Institutional Review Boards
Self-Reported Subspecialty Focus*
(primary and secondary)
by denny smith, contributing writer
interviewing charles allison, md, elise levine, and carla j. siegfried, md
F
or many health care providers, institutional review
boards (IRBs) may seem like
ubiquitous wallpaper in the
bureaucracy of medicine.
But beneath all the paperwork are purposes both powerful and profound—
and the reach of IRBs may extend further than you realize. Here is a quick
primer on when you may need IRB
approval and what that might involve.
The Role and Reach of IRBs
“The job of an IRB is twofold: to protect the patient and protect the integrity of the information gathered in research,” said Carla J. Siegfried, MD, of
Washington University in St. Louis. In
the United States, IRBs are regulated
by the FDA, an agency that has been
accused of both laxity and overzealousness. Generally, however, its record
of oversight has made the United States
arguably the safest country in the
world for drug testing and approval.
IRBs then extend that FDA oversight
to the smallest community-based practice as well as the world’s most powerful research institutions.
Joining AAOE opens the door to valuable
educational and learning opportunities.
Learn more at www.aao.org/joinaaoe.
When Is IRB Approval Required?
“In any context that can plausibly be
regarded as research, there really is
not a lot of wiggle room in what is and
what is not subject to IRB approval,”
said Elise Levine, who serves as both
practice administrator and director
of clinical research at a practice in
Mission Hills, Calif. Pharmaceutical
manufacturers who approach physicians to function as investigators for
an investigational new drug (IND)
protocol will already have secured the
FDA’s approval to move forward with
clinical trials. But all actions related to
physician-investigator recruitment of
patients require IRB approval, said Ms.
Levine.
Are you performing research? “The
whole concept of research is to test
a hypothesis, so it can add to a body
of knowledge,” said Dr. Siegfried. “It
doesn’t have to be [about] a drug or
procedure to qualify as research. And
it doesn’t matter whether the research
is retrospective or prospective. Even
observation of a patient is research that
needs prior approval if it is explicitly
intended to influence medical practice
and is intended to be entered into the
public record and applied prospectively. Always question whether you
are performing ‘research.’” Don’t try to
skip the IRB process or do it after the
fact. Journals require IRB approval before a study is started as qualification
for publication.
Administration / Business. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
I n si d e an I R B
An IRB member’s perspective. The
work of IRB members can be quite
taxing, according to Charles Allison,
MD, who is the longtime chairman of
the IRB at St. Mary’s Medical Center
in San Francisco and who maintains a
private practice nearby.
A rewarding endeavor. Dr. Allison
is an internal medicine physician, not
an ophthalmologist, but in considering new study proposals month after
month as chairman of the IRB, he
keeps abreast of important developments in ophthalmic medicine. “I
have benefited tremendously from
learning about research outside my
own practice. The IRB can be an important vehicle for learning and not
just for regulation.”
An increasingly time-consuming
enterprise. Due to the format required
by the FDA, the protocols for trials
have become extremely verbose over
the years, with lots of repetition, said
Dr. Allison. “The actual material in
them might not be that complicated,
but they run to a lot of pages and are
time-consuming to read.”
Another activity that takes a lot of
time, at least for some IRB members,
is reviewing adverse events, especially
for protocols that include complex
treatments like cancer chemotherapy
drugs, he said.
e y e n e t
Anterior Segment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 934
Cataract / IOL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5,035
Comprehensive Ophthalmology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6,824
Contact Lenses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Corneal Surgery / External Disease. . . . . . . . . . . . . . . . . . . . . . . . . . 1,612
57
Genetics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Clinical Update
Glaucoma.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,873
T R AUM A
From the Frontlines to the Home Front, Part 2
Lessons From the Battlefield
Low Vision Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
by denny smith, contributing writer
interviewing vikram d. durairaj, md, col. (ret.) robert a. mazzoli, md,
and lynn polonski, md
C o u r t e s y o f U n i t e d S tat e s N av y
I
n the words of Hippocrates, “He
who would become a surgeon
should find an army and follow it.” This statement indicates
the millennia-old connections
between the military and medicine.
Throughout the centuries, many innovations formed in the crucible of
combat have found their place in civilian medical care, particularly in emergency settings. Ambulances, wound
debridement and disinfection, blood
transfusion techniques, and medical
evacuation air transport are just a few
of many historical contributions from
military medicine.
Yet given the differences between
the military and civilian arenas, not
all techniques and approaches that
work effectively in a frontline hospital
are necessarily transferable to a community emergency room. What are
some of the promising areas of shared
knowledge and experience?
In Part 1 of “From the Frontlines
to the Home Front,” EyeNet focused
on treatment of gunshot wounds in
combat and in the community. We
continue the conversation, with Vikram D. Durairaj, MD, a professor of
ophthalmology and otolaryngology
and the chief of oculoplastics and orbital surgery at the University of Colorado Hospital (UCH) in Aurora; Col.
(Ret.) Robert A. Mazzoli, MD, former
Consultant to the Surgeon General
of the U.S. Army and former chief
of ophthalmology at Madigan Army
Medical Center in Tacoma, Wash.;
and Lynn Polonski, MD, a clinical as-
Medical Ophthalmology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Role 3 NATO hospital in Kandahar, Afghanistan. On a scale of 1 to 4, Role 3 indicates the availability of multiple specialty medical services.
sistant professor of ophthalmology at
the University of Arizona in Tucson.
This month, these three oculoplastic
surgeons provide their perspectives on
how best to apply the lessons from the
battlefield to the civilian ER.
Combat Experience in the ER
According to Dr. Polonski, physicians
with military service under their belt
may be more comfortable than others
in providing emergency trauma care;
and, just as important, the experience
of military physicians has enriched
the management of ocular trauma
that their civilian colleagues may face.
He said, “Military ophthalmologists
have absolutely, without doubt, helped
the civilian sector,” and listed several
examples of lessons learned (some of
which were discussed at greater length
in Part 1):
• Treatingatraumapatientasearly
as possible is an advantage that was established—beyond question—in Iraq
and Afghanistan.
• Addressingtheconditionofthe
globe is paramount: If it’s ruptured,
then repair it as early as possible.
• Lateralcanthotomiesarecrucial
in relieving high intraocular pressure
(IOP) induced by trauma. Make sure
that everyone in your ER knows how
to perform this procedure and that
they monitor IOP—these steps can
spare the optic nerve from unnecessary damage.
• Lidlacerationsshouldberepaired
within 24 hours, especially full-thickness lacerations. Most of the time all
lid tissue is there, even in significant
trauma, and is still vital, as long as you
have a vascular supply.
• Rememberthatdecisionsmade
e y e n e t
News in Review
comme n ta r y a nd p e r spe c t i v e s
ow does the world appear through glaucomatous
37
Medical Retina. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 543
Neuro-Ophthalmology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370
Ocular Oncology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Ophthalmic Pathology.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Ophthalmic Research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Ophthalmic Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
Optics / Refraction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Pediatric Ophthalmology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 965
Glaucoma Patients:
How They See
H
Medical Education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Tr auma Te ams a t W o r k
UNMODIFIED; NOT AWARE
BLACK TUNNEL
BLURRED TUNNEL
BLACK PARTS
BLURRED PARTS
MISSING PARTS
Plastics / Reconstructive. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,047
eyes? Nothing like the images in patient education brochures and on Internet sites, according
o p h t h a l m o l o g y. 2 013 ;12 0 ( 6 ) :112 0 -112 6 .
to a team of British researchers.1
Popular belief holds that
patients with advanced
bilateral glaucoma see the
world through a black tunnel or have black patches
masking their field of view.
But not one of the 50 participants in a clinic-based
cross-sectional study reported seeing these effects.
Rather, they reported seeing
blur and missing areas.
The study. The participants, recruited from
Moorfields Eye Hospital,
had visual acuity better than
20/30 and a range of glaucomatous visual field defects
in both eyes outside of normal limits on the Glaucoma
Hemifield Test using the
Humphrey Field Analyzer
(HFA). More than one-fifth
had well-advanced visual
field loss in both eyes, specifically, HFA mean deviation worse than –12 dB.
When asked to describe
their visual loss, participants used words like “blur”
and “missing.” They did not
describe a narrowing of the
peripheral visual field.
The researchers also
asked participants to select
one image from among six
displayed on a computer
monitor that corresponded
to the way they see the
world. All the images were
of an identical outdoor
scene, though five were al-
Refractive Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,082
VISUAL VARIATION. Images viewed by study participants.
tered to simulate different
ways of seeing: black tunnel,
tunnel with blurred edges,
black parts, blurred parts,
and missing parts.
Nobody chose the black
tunnel or black parts, and
only 4 percent chose the
blurred tunnel. Instead, 54
percent chose the image
with blurred parts, and 16
percent chose the image
with missing parts. Interestingly, 26 percent of the
participants selected the
image that was not altered,
signifying that they were
completely unaware of their
visual loss.
Although participants
had varying degrees of visual field loss, there was no
e y e n e t
Retina / Vitreous Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,410
Strabismus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
17
Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Ultrasound.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Uveitis / Immunology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
* SOURCE: American Academy of Ophthalmology Membership Data, August 2013.
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