In March 2015, the American-European Congress of Ophthalmic Surgery (AECOS) convened in Aspen, Colorado, for the annual Winter Symposium. Leading ophthalmic surgeons and industry executives gathered for candid conversations on the political and legal landscape and its effect on ophthalmology, the state of the ophthalmic marketplace and opportunities for innovation, the integration of new techniques and technologies, and more.

The Winter Symposium commenced with a tribute to George O. Waring III, MD, an ophthalmic pioneer and esteemed AECOS member. Eric Donnenfeld, MD; Marguerite McDonald, MD; Robert K. Maloney, MD; and George O. Waring IV, MD, FACS, reminisced about George—from his valued contributions to ophthalmology to his infectious spirit and thirst for adventure—inviting all in attendance to commemorate an ophthalmic great and a life lived to the fullest.

INNOVATORS SESSION

Kicking off the Innovators Session, John A. Vukich, MD, shared an update on AECOS, including a new opportunity for members to enhance their search engine optimization through the AECOS website. Dr. Vukich also discussed the status of the AECOS US corneal crosslinking (CXL) trial, which recently concluded with several thousand patients treated at 85 sites—a significant event for both the organization and the public, he said.

Venturing to the political and regulatory landscape, Jeff Kimbell shared takeaways from the 2014 election (“personality still matters”) and offered insights into the 2016 election, which will see the most well-funded campaign, at $1.7 billion by Hillary Clinton. Next, Allison Shuren, Esq, and Alan Reider, Esq, shed light on the things that keep physicians’ lawyers awake at night, illuminating the potential dangers of cataract packages and marketing materials; in addition, they warned that physicians may not be fully prepared for the impact of the Sunshine Act data release and suggested ways in which physicians can ensure that their contracts and financial relationships are compliant with this legislation.

John Doane, MD, presented a look at the status of pharmaceutical pricing structures for a variety of clinical scenarios, including cataract surgery and allergy, and explored the difference between generic and brand name drug costs. Michael Mrochen, PhD, discussed the process of getting an ophthalmic device approved in Europe, dispelling the belief that clinical data are not necessary for approval in the European Union. Next, Alan Carlson, MD, discussed the implementation of new technologies and the art of the patient conversation, which he leads with, “Tell me what you consider to be the ideal result for your eye surgery.”

Looking at practice development and management, Mark Rosenberg discussed three creative succession strategies: maintain status quo, strategic sale, and private equity. Spence Byrum shared a variety of real-world scenarios most physicians would likely be ill-prepared to handle, including a hospital shooting, a complete power outage, and a superbug outbreak.

Touching on AECOS’ mission to promote physician-industry collaboration, a panel of experts was then tasked with considering the question: Can MDs still work effectively with industry? Panelists Guy Kezirian, MD; William Trattler, MD; and Dr. Donnenfeld spoke about physician obligations to consult with industry and how to keep both parties on the same team. They also discussed what young surgeons must know before getting involved with industry and the professional and personal requirements for participating in clinical trials.

The next series of talks within the Innovators Session centered on femtosecond laser cataract surgery techniques and challenges. Stephen G. Slade, MD, provided an update on laser cataract surgery 5 years out, detailing the direction in which outcomes are heading and how the OR setup alone can yield improved patient outcomes, and Robert Weinstock, MD, discussed patient acceptance of the laser in his practice. Dr. Donnenfeld shared a case presentation of a patient with a filtering bleb, in whom he employed a visco-chop technique; as Dr. Donnenfeld predicts, the field is heading toward fluidics-driven lens removal. On behalf of William Wiley, MD, Mitch Jackson, MD, presented his femto philosophy, advising surgeons to first ask patients, “Glasses or no glasses?” and then use the appropriate technology and charge the appropriate price to achieve that goal. Closing out the session, Christian Rathjen, PhD, shared 8-month user experience with the Z8 (Ziemer), which is routinely being used in 12 countries and awaits 510(k) clearance, he reported.

THE MODERN PRACTICE: FEMTO, BUSINESS, PRACTICE GROWTH

Kicking off the Modern Practice session, Arthur Cummings, MD, provided an update on AECOS Europe, sharing reflections on the 2014 European Symposium in Barcelona and projections for the 2015 European Symposium in Berlin.

Next, surgeons took a look at current and future IOL designs. Steven Schallhorn, MD, highlighted the best of the new multifocal IOLs—including Oculentis, ReStor, Tecnis, and Symfony—and shared an overview of the changing patient expectations. Tobias Neuhann, MD, compared trifocal and bifocal lens designs and the associated advantages and disadvantages. Dean Corbett, MD, described a new lens for increased depth of focus, the Symfony IOL (Abbott Medical Optics), and shared results from a clinical trial comparing the lens to a monofocal, in which patients reported no significant difference in glare or halo. Eugene DeJuan, MD, discussed the search for the next accommodating IOL, sharing insight into the FluidVision IOL (PowerVision), the Akkolens, Elenza, and the Alcon Google lens. Last, Dr. Mrochen described advanced ocular modeling for IOL power calculations and the importance of obtaining accurate measurements from the beginning of each case.

Taking a look at some key happenings in the ophthalmic industry, Brent Saunders, of Actavis, shared his perspective on the company’s acquisition of Allergan. Jeff George, of Alcon, shared his predictions for the ophthalmic marketplace and its potential, predicting that eye care will grow by over $10 billion in 5 years. Rounding out the industry perspectives, panelists Cal Roberts, MD, of Bausch + Lomb; Leonard Borrmann, PhD, of Abbott Medical Optics; Mr. Saunders; and Mr. George weighed in on in-house research and development (R&D) versus acquisitions and how to make the United States an epicenter for R&D.

Further exploring opportunities for development, Steven Vold, MD, shared insight into new horizons in glaucoma devices, introducing technologies like the iStent inject, Xen, and InnFocus, and encouraged surgeons to jump into the combined cataract and glaucoma space. Mark Rosenberg and James Dawes chaired a session on growing the ophthalmic business. Mr. Dawes shared insights into creating a model team and tips for the interviewing process. Damien Goldberg, MD, shared pearls for keeping up with the modern digital times while providing personalized patient care, advising physicians to stay connected with peers millennial style but to engage with patients old-school style. Offering another fresh look at practice styles, Jared Younger, MD, discussed patient connectivity and the art of connecting to patients in and out of the office and shared tips for what physicians can do when they receive a negative online review. Last, Dr. Slade and Mr. Rosenberg discussed MIGS as an opportunity to diversify a practice and provide significant value to patients.

NEW TECHNOLOGIES

The New Technologies session began with a keynote lecture from James Mazzo on the ophthalmic marketplace. Mr. Mazzo discussed the forces ophthalmic innovation forward as well as potential challenges facing the market, including stringent clinical requirements and approval processes, health care reform and new layers of compliance, and pressure on R&D budgets. According to Mr. Mazzo, the ophthalmic innovation cycle has become more complex and costly, influencing risk-reward equations. When considering methods to propel innovation and investment in new technologies, Mr. Mazzo advised that investors and strategics are most interested in companies with disruptive technology, proprietary or proven technology, and a team of talented and experienced individuals.

Continuing to explore the status of ophthalmic innovation, a series of products in the pipeline were presented to a panel of key industry and regulatory figures, including Randy Alexander; Judy Gordon, DVM; William Link, PhD; Mr. Mazzo; and Dr. Roberts. After each presentation, the panelists were tasked with judging the likelihood of a product reaching the marketplace by voting “yes” or “too early to tell.” Technologies and treatments discussed included dropless cataract surgery (Imprimis), PiXL (Avedro), Cassini (i-Optics), FluidVision (PowerVision), a small-aperture IOL (XXX), the Light Adjustable Lens (Calhoun Vision), the AcuTarget HD Analyzer (AcuFocus), the VisAbility implant system (Refocus), and a number of new approaches to meibomian gland dysfunction.

With innovation still on the mind, an innovative all-women organization, the American Society of Progressive ENterprising Surgeons (ASPENS), took the stage. Members Sheri Rowen, MD; Cathleen McCabe, MD; Dr. Matossian; Dr. McDonald; Karolinne Maia Rocha, MD, PhD; Jennifer Loh, MD; and P. Dee G. Stephenson, MD, discussed the inspiration behind this society and shared its goals and initiatives to advance ophthalmology and the role of women in the field.

Rounding out the New Technologies session, the Young Ophthalmologists session featured insights from some of the youngest, brightest minds in ophthalmology. Panelists John Berdahl, MD; Jamie Monroe, MD; Dr. Rocha; Dr. Waring IV; and Dr. Wiley fielded questions from moderators Steven Dell, MD, and Dr. Slade on their motivations to enter ophthalmology, preferred practice methods, and thoughts on the future of the field. Wise words from Dr. Slade concluded the session, “As long as you view [practicing ophthalmology] as a gift, you’ll go far.”

PRESBYOPIA AND PREMIUM IOLS
Starting off the session on Presbyopia and Premium IOLs, moderator Dr. Maloney led a panel of experts through a series of case presentations. For each case, panelists Dr. Neuhann; Dr. Trattler; Colman Kraff, MD; and Dr. Goldberg were required to pick the appropriate lens to implant and provide insights into their decision-making process.

Next, a series of Best Case/Worst Case presentations ensued, with surgeons sharing their most and least successful experiences with a particular technology or treatment. Featured topics included: (1) dry eye care by Dr. McDonald, (2) CXL by Dr. Trattler, (3) corneal inlays by Matthias Maus, MD; Greg Parkhurst, MD; and Jeff Machat, MD, (4) topo-guided LASIK by Dr. Cummings; and (5) clear lens exchange for presbyopia by Dr. Kraff. Following, Dr. Thompson shared new thoughts on postop schedules and drop regimens, engaging Dr. Donnenfeld; Mitchell Jackson, MD; and Dr. Wiley in discussion. Last, Dr. Donnenfeld led Richard Baker, OD; Dr. Mrochen; and Dr. Stephenson in a discussion on the best methods for toric IOL calculation and alignment and their recommended practices for astigmatism correction.

LASIK/PRK/ASTIGMATISM

Opening the LASIK/PRK/Astigmatism session, Steven Klyce, PhD, shared the essentials of corneal screening and highlighted new technologies; according to Dr. Klyce, Placido-based corneal topography remains the most sensitive screening tool for keratoconus. Next, Dr. Schallhorn shared LASIK “lessons learned” in a large series, revealing that the biggest driver of patient satisfaction is uncorrected visual acuity. Stephen Coleman, MD, discussed his reasoning for performing only LASIK in his practice, stating, “I truly believe that laser vision correction is LASIK, not PRK.”

Next, Dr. Vukich provided additional details on the AECOS/FDA CXL trial, in which a total of 2,087 eyes were treated at 82 sites. One question evaluated in the study was whether the same irradiance could be delivered with different energy levels. Perhaps the greatest result, however, is that more than 80 sites are now ready to go with CXL—a major contribution by AECOS, Dr. Vukich said.

John Doane, MD, discussed the US FDA trial on SMILE. As of 2014, more than 100,000 SMILE procedures have been performed worldwide, prompting Dr. Doane’s stance that lenticule extraction can compete commercially with more established procedures like LASIK. Dr. Dell led a series of “unhappy patient” case presentations, tasking the audience to weigh in on their suggestions for appropriate management.

Moving to the surgical video space, James Lewis, MD, and Dr. Trattler moderated a panel on HD video surgical technique and complications. Dr. Lewis then shared tips for 4K recording, describing its advantages over HD, including high-quality still image capture and excellent magnification without distortion. Robert Weinstock, MD, discussed heads-up operating with the TrueVision system, reporting benefits for surgeon posture and comfort.

Michael Raizman, MD, presented his experience with a hydrogel technology platform for surgery and drug delivery by Ocular Therapeutix, describing how incisions reported to be self-sealing might, in fact, not be.

Next, AECOS members shared challenging case presentations, inviting all attendees to weigh in on the appropriate treatment approach. Dr. Donnenfeld presented a case of a secondary IOL in a patient with an iris coloboma, and Dr. Waring IV described a case of a cataract in a patient who had undergone LASIK after PRK and had high astigmatism and low endothelial cell density. Looking intraoperatively, Dr. Wiley demonstrated his use of intraoperative aberrometry in a complex cataract case, Dr. Stephenson weighed in on the clinical significance of intraoperative alignment, and Theodore Perl, MD, shared his use of intraoperative OCT to facilitate endothelial graft placement and a femtosecond laser technique for the treatment of recurrent corneal stromal dystrophies.

Overall, the 2015 AECOS Winter Symposium served as an innovative forum for the intimate exchange of ideas among leading ophthalmic surgeons and members of industry. We look forward to the 2015 AECOS European Symposium, taking place June 25-28 in Berlin.