2014 AECOS Summer Symposium: Meeting Highlights

In July, the American-European Congress of Ophthalmic Surgery (AECOS) held its annual Summer Symposium in Deer Valley, Utah. In its fourth year, this dynamic meeting expanded to incorporate a series of extensive, peer-to-peer case discussions on a variety of topics, including challenging cataract and refractive surgeries, ocular surface evaluation and dry eye management, and microinvasive glaucoma surgery (MIGS). Coupled with sessions on the political and regulatory health care landscape, practice styles and management, and cutting-edge technologies and treatments, the 2014 Summer Symposium served as a true forum for physicians and industry leaders to exchange high- level ideas for advancing the ophthalmic field and improving patient care.

The Summer Symposium commenced with the Hot Topics session, which provided attendees with an up-to-date look at health care regulation, innovation, premium practice trends, and practice management. Opening the session, Michael Romansky assessed the challenges in ophthalmic ambulatory surgery center (ASC) payment and policy and the efficacy of the current ASC quality reporting program, with which 98% of ASCs are in compliance, he reported. Next, keynote speaker Jeffrey Shuren, MD, JD, was streamed in from Washington, DC, for a live video conference on the Center for Devices and Radiological Health’s progress since 2012, when a major shift in the determination of benefit-to-risk ratios occurred. Following these enlightening discussions, William Freeman reviewed the business of premium/private-pay ophthalmology, citing the drivers of this market as patient demand, limited public health care funds (reimbursement pressure), and new and improved technologies. Next, Michael Lachman revealed key findings from a 2014 AECOS survey on premium practice trends, revealing that 49% of surgeons are not performing intraoperative aberrometry (primarily due to cost), 38% of surgeons are “very satisfied” with the economics of laser cataract surgery, and 65% of ophthalmologists actively market and advertise outside of the practice. Concluding this session was a comprehensive discussion on the advantages of working with a management service organization from both the administrative (Mark Rosenberg) and physician (Michael Diesenhouse, MD) standpoint.

Moving to the surgical side of ophthalmic practice, the first Case Presentations session focused on pharmaceutical interventions in cataract and refractive surgery and challenges in laser cataract surgery. On the pharma side, case presentations delivered by Christopher Rapuano, MD; Kenneth Beckman, MD; and Steven Dell, MD, highlighted a range of scenarios, including a severe dry eye patient who desired LASIK, a patient with meibomitis who requested cataract surgery, and cataract surgery with rebound inflammation. Next, George Waring IV, MD; Jason Jones, MD; and Daniel Chang, MD, presented their challenging laser cataract surgery cases, including a patient with nanophthalmos and narrow angles, a small pupil case, and femto with a decentered crystalline lens. Discussants assigned to each case proposed their own assessments and treatment plans, allowing for a comprehensive exchange of surgical pearls.

Transitioning to glaucoma, the next Case Presentations session incorporated three MIGS cases for review and discussion. First, Carlos Buznego, MD, described a patient with a cataract and advanced glaucoma who desired improved vision and was thus managed with combined cataract surgery and iStent (Glaukos) implantation. Second, Steven Vold, MD, presented his tips and tricks for MIGS, stressing the importance of proper patient selection and angle visualization in patients implanted with the iStent. Third, Richard Lindstrom, MD, analyzed MIGS market status and growth opportunities, referring to the combined cataract and iStent approach as a “do-no-harm procedure” with good reimbursement and better-than-expected efficacy.

In the Broadening the Premium Channel session, moderators Tal Raviv, MD, and Dr. Waring IV led a business savvy panel featuring Richard Awdeh, MD; Dr. Beckman; and Jai Parekh, MD, in a discussion on new tools and treatments for the premium practice. Kicking off the session, Robert Cionni, MD, explored the adoption of premium IOLs, stating it is lower than expected, primarily due to lack of surgeon confidence in meeting patient expectations; however, as Dr. Cionni reported, image-guided systems may change this scenario and increase the adoption rate. Next, Nicholas Batra, MD, compared toric IOLs with femtosecond laser cataract incisions, describing the advantages afforded by use of the LenSx Laser (Alcon) and intraoperative aberrometry. In another look at methods for surgical precision, William Wiley discussed the capabilities of surgical guidance systems, describing tips for intraoperative toric IOL alignment and comparing features of the TrueGuide (TrueVision), Callisto (Carl Zeiss Meditec), and Verion (Alcon) devices. Following, a lively point-counterpoint on laser cataract surgery ensued, with Robert Maloney, MD (pro), and John Doane, MD (con), on the capabilities, expense, and patient satisfaction associated with the procedure. Dr. Waring IV shared his approach to refractive lens exchange in patients diagnosed with so-called dysfunctional lens syndrome, stating that the terms very early cataract and pre-cataract are dismissive. Shamik Bafna, MD, considered how to express the value of each premium add-on, reminding attendees that creation of the proper patient mindset starts at the front desk, and Dr. Buznego explored the cost of generic versus branded drops and how changing price structures—namely the skyrocketing of generic drug costs—affect the premium practice and patient care. Last, John Sheppard, MD, demonstrated how he transformed dry eye treatment into a profit center, identifying provider leadership, a doctor champion, and engaged administration as the requirements for dry eye practice optimization.

Back in the cataract surgery space, moderators Bonnie An Henderson, MD, and Dr. Cionni led a series of complex cataract presentations, in which surgeons shared pearls for the management of lens coloboma, intumescent cataracts, dislocated toric IOLs, posterior capsular rupture, and more. Several presenters also weighed in on how the addition of the femtosecond laser affects the management of complex cases, with Kasu Prasad Reddy, MD, on capsulotomy challenges in laser cataract surgery and Doug Koch, MD, on whether the management of subluxated lenses is improved with the use of the laser. Having recently returned from Ethiopia, where he performed more than 400 cases in 6 days, Geoffrey Tabin, MD, helped attendees visualize high-volume, high-quality cataract surgery in the developing world, where nearly 100 million people are blind due to cataracts.

Amidst the new legislation and health care regulations physicians are adapting to, Jeffrey Kimbell provided a timely 2016 Presidential Election Update, with a glimpse at the potential candidates and platforms for the impending race. Following, the Practice Performance Session, moderated by James Dawes, Mr. Rosenberg, and Dawn Thompson, opened with an insightful conversation about implementing change in a practice and lessons learned along the way. Next, in the EHR Ultimate Showdown, a range of perspectives on electronic health records (EHR) faced off, with Dr. Doane on why EHR is a necessary evil, Mr. Rosenberg on why EHR is a huge asset to Barnet Dulaney Perkins Eye Center, and Nancy Tanchel, MD, on why EHR is something she wishes she had never done. When the dust settled, keynote speaker Tera Roy, of NextGen Healthcare, shared her perspective on the reasons EHR is being implemented (eg, personal health monitoring), how it will ultimately benefit physicians, and why it fits with the millennial generation and their incentives to stay healthy. Next, Alan Reider, Esq, and Allison Shuren, Esq, presented a series of real-world situations that they deemed either “stupid mistakes” or “understandable confusion” in the world of health care compliance. Last, Brad Houser discussed how to develop a strong customer service culture, measure how your practice is doing, and capitalize on happy patients.

Another enlightening round of case presentations was then held, focusing on premium procedure management cases, moderated by Vance Thompson, MD, and Dr. Koch. First, Eric Donnenfeld, MD, presented a case of a patient with a red, burning, dry, itchy eye who presented for LASIK. In addition, Dr. Waring IV shared a case of refractive lens exchange in a middle-aged patient seeking maximum spectacle independence. In both scenarios, the surgeons were required to determine the best treatment plans while keeping in mind these specific patient demands.

Taking a moment to recognize a true leader in the field of ophthalmology, Dr. Dell, President of AECOS, presented the AECOS Visionary Award to Dr. Henderson. After accepting her award, Dr. Henderson delivered an Award Lecture on the Ten Things They Didn’t Teach Me in Residency. A few of her lessons learned—of value to both new and seasoned ophthalmologists—included: life is unpredictable, you cannot please everyone, never make a decision based solely on money, and be your own advocate.

Returning to the surgical realm, Alan Crandall, MD, and Dr. Cionni led a series of video case presentations featuring surgeons’ “best pearls.” Presenters shared pointers for managing a variety of surgical scenarios, including zero-phaco femto, intraoperative floppy iris syndrome/small pupils, subincisional cortex removal with manual and femtosecond laser-assisted cataract surgery, intraoperative gonioscopy, astigmatism management, pseudoexfoliation, and Malyugin ring (MicroSurgical Technology) insertion with a visco-assist technique. Dr. Cionni then polled the audience members on which pearl they found most valuable, settling for a three-way tie.

On the cutting edge, the Innovations Session, moderated by William Link, PhD, and James Mazzo, showcased a range of innovative treatments and technologies. Dr. Bafna described the use of slow-release dexamethasone-filled punctal plugs at the time of cataract surgery, reporting reduced pain and inflammation in a phase 2 study. Next, William Trattler, MD, described his use of intraocular medications during cataract surgery with the goal of reducing or eliminating postoperative drops and associated issues of cost and compliance. Robert Rivera, MD, weighed in on why the Light Adjustable Lens (Calhoun Vision) is effective, reporting that the lens yields LASIK-like results in a cataract age group, and Terry Kim, MD, described a pharmacologic treatment for presbyopia that relies upon the pupil to expand the depth of focus and reportedly lasts 8 hours. Last, Dr. Raviv highlighted mobile applications that physicians can use to optimize productivity both in and out of the clinic, including MediBabble (NiteFloat), an interpretation app that health care providers can use to communicate with non-English- speaking patients, and PDF Expert (Readdle), which enables users to read, annotate, and edit PDF documents on an iPad or iPhone.

The Corneal Refractive Surgery for Pros session, moderated by Mitchell Jackson, MD, and John Vukich, MD, launched with a presentation on LASIK: Thoughts on the Market and the Future, by Stephen Slade, MD; despite bad press in recent years, Dr. Slade reported that he doubts there will ever be a procedure that is as productive for the clinic and yields so many happy patients as LASIK. Next, Doyle Stulting, MD, described the efficacy of the Ectasia Risk Score System, concluding that there is a need to create an easily applicable screening system to avoid ectasia 100% of the time. Then Dr. Doane and Dr. Trattler weighed in on LASIK at the extremes, deliberating how steep is too steep and whether corneal thickness is an accurate indicator of the cornea’s structural stability. Simon Holland, MD, described factors to consider in determining whether to perform wavefront-optimized versus topography-guided treatments in eyes with minimal corneal irregularity, and William Culbertson, MD, reported his experience with ReLEx SMILE, noting the advantages include that it requires one laser, saves time and money, and leaves an anterior 120 μm of cornea intact. Looking at inlays, Dr. Vukich, MD, gave an update on the regulatory status of the small-aperture corneal Kamra inlay (AcuFocus) in the United States, and Ralph Chu, MD, shared results achieved in the FDA IDE study evaluating the Raindrop near-vision inlay (ReVision Optics), which has an implantation technique similar to LASIK, he said. Last, George Waring III, MD, discussed the use of the customized aspheric treatment zone (CATz) ablation profile, reporting reduced spherical aberrations and coma.

The Summer Symposium concluded with a joint session between AECOS and the Cross- Linking Congress, moderated by Dr. Stulting and Dr. Trattler. Kicking off, Dr. Jackson described surface ablation versus corneal collagen crosslinking (CXL) in patients with forme fruste keratoconus, reporting that international literature suggests simultaneous topo-guided PRK and CXL is superior to sequential CXL with later PRK. Next, Dr. Kim discussed surface ablation for refractive enhancements following presbyopia-correcting IOL implantation, and Richard Lindstrom, MD, shared his initial experience of CXL combined with CK, stating that visual acuity improves with CXL + CK + Intacs but not with CXL + CK alone. Yaron Rabinowitz, MD, described phototherapeutc keratotectomy (PTK) plus CXL as an optimized method for epi-off CXL, reporting that PTK removal of the epithelium achieves greater flattening than debridement, and Dr. Holland shared pearls for topography-guided PRK for keratoconus and post-LASIK ectasia. Marguerite McDonald, MD, discussed contralateral comparisons of the Nexis Vision Corneal Shield (Nexis Vision) and surface ablation, reporting that use of the shield yielded faster visual and functional recovery compared with conventional LASIK. Dr. Stulting shared results of the Wavelight T-CAT clinical trial, revealing that topo-guided LASIK using the T- CAT algorithm provides excellent UCVA, with 65% of eyes seeing 20/16 or better. Concluding the session was Dr. Thompson on the use of Brillouin spectroscopy for measuring corneal biomechanics, a technique used to directly map corneal stiffness in a clinical setting, with potential application in the preoperative screening of refractive surgery patients.