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Academy Live
Sunday, October 25, 2009 Twitter

Guest Medical Editors: Franco Recchia, MD
Managing Editor: Susanne Medeiros | Editors: Patty Ames, Chris McDonagh and Denny Smith
Writers: Lori Roniger, Lori Baker Schena, Linda Roach and Annie Stuart

AE Mobile View Academy Live on your handheld device

Here is a further installment of highlights from the Academy in San Francisco.

EYENET BLOG@THE ACADEMY: Ready or Not, Health Care Reform is Coming!

Jackson Memorial Lecturer challenges conventional science on angle-closure glaucoma
In delivering the Jackson Memorial Lecture, Harry A. Quigley, MD, challenged what we previously thought is the primary cause of angle-closure glaucoma (ACG). 

If you have 10 people with narrow angles, only one will develop ACG. But we don’t currently have a good way to identify who that person is, he said. The importance of this can’t be underestimated as the numbers of people going blind from ACG is on the rise, particularly in countries such as China, where 50 million people are currently at risk of developing ACG.

But new OCT imaging technology has allowed glaucoma specialists to view the condition in more detail, revealing the physiological aspects of the disease and providing new insights into possible risk factors.

Using imaging technology, Dr. Quigley and his colleagues have shown that in normal eyes when a pupil is dilated in darkened conditions the iris loses half its volume. “Essentially your iris is a sponge and it loses half its size when it’s dilated—and it happens quickly, water is moving in and out in less than five seconds,” he said.  But patients with ACG lose less iris volume with a change in pupil diameter. Two large, long-term studies are ongoing in China to determine if this is indeed our first identifiable risk factor for ACG, Dr. Quigley said.

As a result we may need to reevaluate static measurements of the eye and begin taking measurements under various conditions.

His work has also illuminated the role of the choroid in causing the positive pressure exhibited in eyes with ACG. He has found that when the choroid expands by 20 percent, IOP rises to 60 mmHg, suggesting the significance of measuring provoked choroidal expansion in ACG patients.

Dr. Quigley’s work is also challenging conventional thinking on malignant glaucoma, a rare complication of glaucoma filtration surgery in patients with narrow-angle or angle-closure glaucoma, suggesting that it’s not a case of “misdirected aqueous.” Instead, he proposes that dehydrated and compressed vitreous with a decreased fluid conductivity establishes a vicious circle of elevated pressure and anterior chamber shallowing.

The full text of Dr. Quigley’s Jackson Memorial Lecture will be published in the November issue of American Journal of Ophthalmology.

In addition to the Jackson Memorial Award, a number of other awards were bestowed during Opening Session ceremonies. Among the honorees were Col. Donald A. Gagliano, MD, on behalf of military ophthalmologists, Hamza H. Al-Majedi, MD, and Tara Reshid, MD, representing the Iraqi Ophthalmological Society, and Michael W. Brennan, MD, honored by Iraqi physicians for his years of advocacy for Iraqi medicine. A full list of the honorees is in the Final Program.


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Investigations continue into reports of IOP spikes following VEGF inhibitor use
Research is ongoing into the causes of cases of IOP spikes following bevacizumab (Avastin) or ranibizumab (Lucentis) use that have been reported around the United States, Malik Y. Kahook, MD, said at Glaucoma Subspecialty Day on Saturday. An active researcher on this topic, Dr. Kahook said he knows of more than 50 cases of IOP spikes after bevacizumab use and a smaller number after ranibizumab use. He said most of these patients don’t experience obvious inflammation, have no previous history of glaucoma or ocular hypertension, and sustain high IOP levels for weeks or months that often require laser therapy or surgery.

In an effort to elucidate the causes of these IOP elevation cases, Dr. Kahook and his colleagues tested bevacizumab samples from multiple compounding pharmacies and found noticeable variability in the concentration of the active monomer IgG, which in many cases was much less than the expected 25 mg/ml. Further investigations showed that some of the particles were much larger than expected.

“We believe that these molecules either plug the outflow pathway or may result in subclinical inflammation in the outflow pathway that then leads to elevation in eye pressure,” Dr. Kahook said during an interview. “We do not think that this is an issue with the active IgG monomer of Avastin, and we are not saying that people should stop using Avastin.”

Dr. Kahook recommends further study of the Avastin compounding and shipping processes to ensure greater product consistency between compounding pharmacies and to decrease the chances that high molecular weight adducts cause aqueous outflow obstruction and subsequent IOP elevation in additional patients. Studies are also being conducted to examine the potential link between IOP spikes and ranibizumab use.

Dr. Kahook has previously received research support from Genentech but has not received funding from Genentech for studies on this topic.

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Diabetic macular edema: Steroid implants start to deliver the goods
At yesterday’s Retina Subspecialty Day, Baruch D. Kuppermann, MD, PhD, provided a sneak peek at the reservoir and biodegradable steroid implants that may soon play a role in ocular drug delivery for diabetic macular edema (DME).     

Already FDA-approved for uveitis, Bausch & Lomb’s fluocinolone acetonide (Retisert) implant—sutured to the sclera where it can last up to 1,000 days—has also been tested for DME. Clinical trial results showed visual acuity gain, macular edema resolution, and diabetic retinopathy stabilization, said Dr. Kuppermann. But concerns over side effects of cataract and glaucoma led the company not to file for FDA approval for DME. 

Alimera Sciences’ Iluvien fluocinolone acetonide reservoir implant contains half as much drug to reduce the side effects seen with Retisert. The Iluvien implant is injected with a 25-gauge needle and floats in the vitreous cavity. Once empty, the nonbiodegradable polymer husk remains in place. Results of the phase 3 FAME trial for DME could be out by the end of this year.

Releasing triamcinolone, SurModics’ I-vation has a corkscrew design that increases the surface area for drug delivery. Screwed into the eye, the implant anchors to the sclera. At 36 months, the phase 1 study has shown macular edema reduction but also cataracts.

Called Ozurdex in the United States and Posurdex elsewhere, Allergan’s dexamethasone drug-delivery system is an injectable biodegradable copolymer implant approved by the FDA in June 2009 for persistent macular edema due to vein occlusion. In phase 2 trials involving DME patients, 35 percent of eyes receiving 700 micrograms improved 10 letters or more by Day 90, compared with 24 percent of those receiving 350 micrograms, and 13 percent in the observation group.

Dr. Kuppermann receives grant support from Alimera Sciences, is a consultant for SurModics and is a consultant and lecturer for Allergan and receives grant support from Allergan.

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Avoid these “top five” uveitis treatment mistakes
Gary N. Holland, MD, warned attendees at Retina Subspecialty Day on Saturday to avoid making the five most common mistakes in treating uveitis.

He told them that uveitis is a complex group of disorders for which treatments are rapidly evolving. Consequently, patients do not always get the careful, immediate and aggressive treatment regimes that uveitis specialists and immunologists have developed, he said.

He cited and gave solutions to the “top five” uveitis treatment mistakes identified in a member survey by the American Uveitis Society (based on frequency or clinical importance):

  1. Treatment errors, such as inappropriate use of cycloplegics, tapering corticosteroids too rapidly, delaying systemic treatment and using medications at doses that are too low.

Solution: Treat inflammation early and aggressively.

  1. Failed or incorrect management of complications, such as glaucoma, and performing surgery on inflamed eyes.

Solution: Monitor the patient closely and act on the findings.

  1. Inappropriate laboratory testing, resulting in too few tests or a potpourri of tests that are not targeted to the suspected cause. This leads to false or unrelated findings.

Solution: Individualize the lab testing.

  1. Lack of attention to findings, such as the location of the inflammation, the onset, the course, and signs of infection.

Solution: Pay careful attention to the history and the clinical exam.

  1. Underuse of available resources, such as rheumatologists, pediatric ophthalmologists and low vision specialists.

Solution: Use a team approach to uveitis.

The wrong treatments can allow the inflammatory process at the front of the eye to spread to the macula, eventually causing irreversible vision loss, he said. Or, in the words of a colleague whom Dr. Holland quoted anonymously, “It’s probably too late to refer a patient after he’s blind.”

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Health care reform debates in D.C. underscore many discussions in San Francisco
“Never in the history of the Academy have the debates in Washington been this critical to the practice of medicine,” said David W. Parke II, MD, executive vice president and CEO of the Academy, during the Opening Session.

Even though a bill that would have permanently adjusted the Sustainable Growth Rate (SGR) formula went down in defeat in Congress last week, there is still hope because the House bill remains committed to it. If nothing is done, medicine faces steep cuts in the future, beginning with the 21 percent cut scheduled for Jan. 1, 2010.

Now is the time to get involved, Dr. Parke said, “The first thing you can do is give. Money is the mother’s milk of politics. If you have a relationship with a congress member, use them. Send an e-mail. Our Web site makes it easy to do this.”

You can also visit the Federal Affairs booth at the Academy Resource Center, in Moscone North, Booth #3569, where staff members can walk you through how to use the Web site to send personalized letters to your representatives.

Learn more about the how the health care reform debates will affect you by visiting the Advocacy page on the Academy’s Web site or listening to this podcast with Dr. Parke.

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Stop: You haven’t seen it all
Did you know that there are exhibit halls in all three of Moscone’s buildings? Exhibitors are located on the first floor of Moscone Hall West, and on the lower levels of both the North and South buildings.

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Best Papers
At the conclusion of each Academy Free Papers session an expert panel confers and selects the paper they considered the best of the group. The Best Papers of today are:

Retina Morning Session:
Genome-Wide Association Study Reveals New Loci Associated with Patient Response to Ranibizumab Treatment for Neovascular AMD, presented by Jason S. Ehrlich, MD (Event Code PA004)

Retina Afternoon Session:
Feasibility of Intraoperative Spectral Domain OCT, presented by Susanne Binder, MD (Event Code PA014)

Safety and Efficacy of Ranibizumab (Lucentis) in Patients with Macular Edema Secondary to Central Retinal Vein Occlusion: The CRUISE Study, presented by Wendy Yee, MD (Event Code PA022)

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Be the first to share, connect on the O.N.E. Network
The Academy is encouraging early adopters of the new Professional Networking and Community features on the Ophthalmic News and Education (O.N.E.™) Network to give us feedback as we prepare to roll out a full set of features starting January 2010. Send comments, ideas and inquiries to
community@aao.org. The Academy is also looking for volunteers to author contents for an upcoming “EyeWiki.” If you’re interested in contributing, send an e-mail to Ryan Plumb at rplumb@aao.org. Check out the new features now at www.aao.org/ONE and log in with your username and password.

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EyeNet provides you with all of the information you need to make the most of the Joint Meeting. Be sure to check out EyeNet's Joint Meeting Publications:

* EyeNet Selections: Glaucoma and Cataract & Refractive Surgery
* EyeNet's Guide to Academy Exhibitors
* EyeNet's October Issue

* EyeNet’s Academy News, Friday/Saturday Edition

* EyeNet’s Academy News, Sunday/Monday/Tuesday Edition

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