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Academy News Atlanta 2008 Academy News Atlanta 2008 Document Transcript

  • TABLE OF CONTENTS FROM THE EDITOR Subspecialty Day is here, and you have questions. IN THIS ISSUE: Highlights of Subspecialty Day . . . . . . . . .4–7 What is the defin- This edition of Academy News itive approach to Alan C. Bird, 2008 Academy Laureate . . . . . .8 retinal vasculitis? focuses on Subspecialty Day. 25 years with the excimer laser . . . . . . . .9–10 Does eye muscle Program directors tell what’s surgery improve OMIC and indemnity payments . . . . . . .11–13 new at their meetings, OMIC vision in kids lists the biggest malpractice claims, and MD pioneers Atlanta aquarium . . . . . . . . . . . . . . . . .17–18 with nystagmus? Can corneal look back at excimer laser milestones. Meet the honorary lecturers . . . . . . . . . .19–22 inlays solve presbyopia? What’s the news from glaucoma studies? You might find intriguing answers to those questions in this year’s Sub- specialty Day programs. And this year, in particular, we will be treated to a bumper crop of offerings, from special tracks in cornea, uveitis and pediatrics to the perennial pillars of glaucoma, retina and refractive surgery. The presentations begin Friday with “Refractive Surgery 2008: The Danger Zone,” and “Retina 2008: Vistas and Viewpoints.” Saturday is even busier, with the addition of “Cornea 2008: Emerging Trends: Evolution or Revolution?” “Glau- coma 2008: The Pendulum Swings,” ”Pediatric Ophthalmology 2008: Basics and Breakthroughs in Managing Strabis- mus and Pediatric Eye Disease,” and “Uveitis 2008: How Should We Diag- nose and Treat Our Patients?” Welcome to Atlanta, and please join your colleagues for the best research and clinical updates of the year. Richard P. Mills, MD, MPH Chief Medical Editor, EyeNet Magazine ON THE COVER Hemangioblastoma Photo by Matt Raeber Barnes Retina Institute e y e n e t ’ s a c a d e m y n e w s 3
  • SUBSPECIALTIES FROM CORNEA TO UVEITIS Highlights of the Subspecialty Day Programs by miriam karmel, contributing writer GLAUCOMA T he six Subspecialty Day programs approached some of the directors of the brief will give you a sense of what’s going offer so much in their packed agen- programs to see what they consider the on in other areas. The pendulum swings. das that the biggest challenge will big news in their fields and what might Example: Fifty years ago, blood flow be deciding which presentations you’ll be of greatest interest to those in other CORNEA was regarded as the culprit in glaucoma. want to attend. In order to help you better subspecialties. Even if you prefer to stick Cornea Subspecialty Day opens on a his- That theory was superseded by intraocular plan your Subspecialty Day, EyeNet strictly to your own subspecialty, this torical note, with a talk about the evolution pressure. Today, the notion that damage of keratoplasty by Mark J. Mannis, MD, to the optic nerve results from an insuffi- and concludes with experts predicting ciency of blood flow is in resurgence, said what’s in store over the next five or 10 years Henry D. Jampel, MD, MHS, a codirector for ophthalmology in general, and cornea of the Glaucoma Subspecialty Day pro- in particular. The audience can expect to gram. Or consider the role of central hear “what’s current, what’s new and what corneal thickness in calculating IOP. For may be new five years from now,” said the past six or seven years, the importance Michael W. Belin, MD, one of the Cornea of corneal thickness “got taken to sort of Subspecialty Day program codirectors. an extreme,” Dr. Jampel said. “Now there’s NEWS IN CORNEA. The agenda includes a swinging back to thinking that corneal updates on surgical techniques for DSEK, thickness is a little bit important, but not full-thickness penetrating keratoplasty, critical.” anterior segment reconstruction and Such swings provide the focus for this lamellar replacement. “Each procedure year’s Glaucoma Subspecialty Day.“There’s has its benefits and limitations,” Dr. Belin an initial enthusiasm, followed by an over- said, adding that the presenters will convey reaction, then a reassessment of where how to find the best procedure for each things really are,” Dr. Jampel said. “Topics patient. go in and out of vogue.” “We used to do full-thickness corneal Even the American Glaucoma Society transplants. We still do. They’re still effec- Subspecialty Day Lecture by Paul P. Lee, tive,” Dr. Belin said. But now, whenever MD, JD, about caring for glaucoma possible, rather than replacing the entire patients has a revisionist ring to it— cornea, doctors try to selectively replace “Back to the Future.” layers, he said. “Maybe in the future, we’ll NEWS IN GLAUCOMA. On the late-breaking be able to replace a single cell layer. This news front, the three-year results of the selective approach to corneal replacement, Tube vs. Trabeculectomy study will be still in its infancy, is what’s really new, announced. And in response to popular what’s revolutionary.” demand, an expanded surgery section will Also, experts will take opposing view- provide an overview of what Dr. Jampel points on applications in corneal and ante- called “a bewildering array of surgical rior segment imaging technologies, which techniques,” as well as newer surgical have undergone changes in the last few approaches. years. And you can expect new informa- OF INTEREST TO THE NONSPECIALIST. Do tion on infectious keratitis, with high- you have an OCT in your office? Are you lights on treatment modalities and new thinking of buying one, or some other and emerging drugs. diagnostic device? Speakers will share OF INTEREST TO THE NONSPECIALIST. While surgery dominates the agenda, this year’s Subspecialties, continued on page 6 program offers a topic of widespread interest—pigmented lesions, tumors and nodules of the anterior segment. “We’ve gathered a panel of international experts to make sense out of what is, for almost everyone—the general ophthalmologist OPHTHALMIC IMAGES CD, VERSION 3.0 and the subspecialist—a confusing topic,” Dr. Belin said. The final section, which is titled “You May Think I’m Crazy, But . . .,” promises to be a fitting ending to an ambitious agenda, Dr. Belin said. “We tried to put a program together where each section TRABECULECTOMY OR TUBE? The three- relates to the others and gels at the end.” year results of the Tube vs. Trabeculec- Cornea Subspecialty Day takes place on tomy study are to be announced at Saturday in the Thomas B. Murphy Ball- Glaucoma Subspecialty Day. room 3/4. T I M E C H A N G E S & C A N C E L L AT I O N S This publication was printed in advance of the Joint Meeting. Check the Ticket Sales area in Hall A-2 for cancellations or changes in meeting times. 4 f r i d a y G s a t u r d a y e d i t i o n
  • SUBSPECIALTIES Subspecialties, continued from page 4 have widespread appeal, as glaucoma isn’t codirector for Pediatrics Subspecialty Day. the only subspecialty confronting industry To be sure, strabismus is on the agenda. their diagnostic testing experiences. You influence, Dr. Jampel said. The Saturday afternoon session, geared to can expect to hear: “This is how I use the Glaucoma Subspecialty Day takes place the subspecialist, will cover “the higher- OCT clinically for glaucoma,” said Dr. on Saturday in the Sidney J. Marcus Audi- order concepts in strabismus—for exam- Jampel. torium. ple, when is strabismus a neurologic prob- Finally, fireworks are likely when Paul lem?” Dr. Siatkowski said. R. Lichter, MD, and Paul F. Palmberg, PEDIATRIC OPHTHALMOLOGY Also, strabismus surgery will be high- MD, PhD, debate the prickly question of After a three-year hiatus, the pediatric lighted in this program’s Keynote Address, whether the pharmaceutical industry is, ophthalmologists are back, with an array when Joseph L. Derner, MD, PhD, who or is not, beneficial to patients. The “Indus- of topics. “Not just strabismus,” promised laid the groundwork for understanding try Relations” section, new this year, should R. Michael Siatkowski, MD, a program the anatomy of extraocular muscles, dis- cusses the implications of pulley systems LATE-BREAKING TOPIC. During Pediatric for modern strabismus surgery. “He’ll dis- Ophthalmology Subspecialty Day, there THE YEAR IN REVIEW: Join the Editors of cuss how that anatomy affects the surgery will be an update on retinopathy of AJO, Archives and Ophthalmology we perform and when surgery on the pul- prematurity care in the neonatal ICU. leys is appropriate,” said Dr. Siatkowski, A mid the demands of practice, the busy clinician doesn’t always find time to keep adding that a goal of the session is to get NEWS IN REFRACTIVE SURGERY. In response up with the peer-reviewed journals. The editors of the American Journal of Oph- doctors to start incorporating pulley sys- to a question from Refractive Surgery Sub- thalmology, Archives of Ophthalmology and Ophthalmology invite you to a review tems into their surgery planning. specialty Day codirector Steven C. Schall- of interesting research published during the last year that has had immediate clinical NEWS IN PEDIATRIC OPHTHALMOLOGY. On horn, MD, seven prominent surgeons will relevance to the profession. tap, in the final “Hot Topics” segment, will reveal their “No. 1 pearl.” Said Dr. Schall- The main criteria for selection by the editors include clinical relevance, interest to be debates on three of the most controver- horn, “They’ve got to decide what that comprehensive ophthalmologists, and a contribution that 1) warrants consideration of sial topics in pediatrics today. In a point- one thing is.” a change in recommended clinical practice, 2) appears to prove or disprove something counterpoint format, experts will consider A session titled “Refractive Surgery in that ophthalmologists have been doing previously but based on less solid evidence or photoscreening and whether it’s ready Unique Patients” covers refractive surgery 3) gives better insight into a disease. for widespread implementation. They’ll in aviators, pilots and children, as well as also discuss whether eye muscle surgery in patients with autoimmune disease, nys- THE EDITORS’ CHOICES SYMPOSIUM Presenter: William R. Freeman, MD can improve vision in children with nys- tagmus or handicaps. Also on the agenda, MONDAY Discussant: Janet L. Davis, MD tagmus. And finally, they’ll talk about experts will address the question: “What Time: 10:15 a.m. to 12:15 p.m. Mechanism of Action of Bimatoprost, whether IOLs are appropriate in children have I done differently this year?” This Room: Thomas B. Murphy Ballroom 4 Latanoprost, and Travoprost in Healthy younger than 12 months. “IOLs are now session promises to touch on everything Fee: No charge Subjects: A Crossover Study well accepted for kids older than 1,” Dr. from new techniques to managing the The line-up is as follows: Presenter: K. Sheng Lim, MD Siatkowski said. “But are we ready to use impact of the economic slowdown on the Discussant: Douglas R. Anderson, MD them in infants?” business of refractive surgery. Preventing Surgical Confusions in Ophthal- On the late-breaking front, there will OF INTEREST TO THE NONSPECIALIST. Dur- mology Prevalence of Plateau Iris in Primary Angle be updates on refractive surgery and ing the “Business Strategies” session, the Presenter: John W. Simon, MD Closure Suspects: An Ultrasound Biomi- retinopathy of prematurity as it relates “experience economy” will receive special Discussant: Joe R. McFarlane Jr., MD croscopy Study to changing NICU practices. coverage, Dr. Schallhorn said. The next Presenter: Tin Aung, PhD Ten-Year Follow-up of Laser In Situ Ker- OF INTEREST TO THE NONSPECIALIST. The step beyond the service economy is the Discussant: Jeffrey M. Liebmann, MD atomileusis for High Myopia morning session will provide a forum for experience economy, in which business Presenter: Jorge L. Alió, MD, PhD Systematic Internet-Based Review of Com- educating comprehensive ophthalmolo- creates a memorable experience for the Discussant: Jay S. Pepose, MD, PhD plementary and Alternative Medicine for gists who deal with children and who treat customer, and Shareef Mahdavi, an expert Glaucoma adult strabismus. “They’re going to get a in this area, will talk about his field as it A Modified Technique for Descemet-Strip- Presenter: Daniel G. Ezra, MBBS protocol to follow, including a tool kit for relates to refractive surgery. In ophthal- ping Automated Endothelial Keratoplasty to Discussant: Lloyd Hildebrand, MD how to measure vision in children, as well mology, for example, the tendency is to Minimize Endothelial Cell Loss as the state-of-the-art treatment for think that the next level of care is better Presenter: Massimo Busin, MD Does Pre-Verbal Photoscreening for Amblyo- amblyopia,” Dr. Siatkowski said. “We want phaco machines, better LASIK, better Discussant: Edward J. Holland, MD genic Factors Affect Outcomes in Amblyopia the comprehensive ophthalmologist to feel imaging devices, Dr. Schallhorn explained. Treatment? Early Objective Screening Yields Rosiglitazone May Delay Onset of Prolifera- comfortable examining and evaluating Dr. Mahdavi will discuss why that’s only Good Acuities tive Diabetic Retinopathy kids with a variety of problems that don’t partly true. “The real game is improving Presenter: Robert W. Arnold, MD Presenter: Lloyd P. Aiello, MD, PhD require the subspecialist level of care.” the patient’s experience,” Dr. Schallhorn Discussant: Elias I. Traboulsi, MD Discussant: Susan B. Bressler, MD Pediatric Ophthalmology Subspecialty said, drawing an analogy to Starbucks, Keep up with AJO, Archives and Ophthalmol- Day takes place on Saturday in Room which offers aroma and ambience along Early Bevacizumab Treatment of Central ogy by reading EyeNet Magazine, where A412. with its coffee. “It’s a real shift in offering Retinal Vein Occlusion selected summaries from these publica- care,” Dr. Schallhorn said. Presenter: Richard F. Spaide, MD tions are featured in the Journal High- REFRACTIVE SURGERY Refractive Surgery Subspecialty Day Discussant: Travis A. Meredith, MD lights section. Why does one post-LASIK patient com- takes place on Friday and Saturday in the Three-Dimensional Spectral-Domain Optical Full access to both AJO and Ophthal- plain about dry eyes and the other does Thomas B. Murphy Ballroom 1/2. Coherence Tomography Images of the Retina mology is available to Academy members not? Who are the unhappy LASIK patients? in the Presence of Epiretinal Membranes via the O.N.E. Network Is there a way to prevent their dissatisfac- RETINA Presenter: Carmen A. Puliafito, MD, MBA EyeNet is the clinical newsmagazine of tion? In one of the three Keynote Address- For two days, retina specialists are being Discussant: Richard F. Spaide, MD the Academy and is mailed to all domes- es at Refractive Surgery Subspecialty Day, treated to the latest information on every- OPHTHALMIC IMAGES CD, VERSION 3.0 tic members. Access to the online version Jennifer Morse, MD, a psychiatrist who thing from gene therapy for inherited dis- CFH and LOC387715/ARMS2 Genotypes and is available to all members, domestic and studies patient response to surgery, will eases to new instruments and innovations Treatment With Antioxidants and Zinc for international, at shed light on what makes patients tick. for management of vitreoretinal diseases. Age-Related Macular Degeneration International members who pay a shipping Dr. Morse was among those who But if any one topic stands out, it is age- Presenter: Michael L. Klein, MD and handling fee of $76/year receive the addressed the FDA’s ophthalmic device related macular degeneration, which dom- Discussant: Paul Sternberg Jr., MD print version of EyeNet. group last spring at a meeting that made inates most of the first day’s agenda. “A Vision Function in HIV-Infected Individuals The EyeNet Web site and the O.N.E. the headlines in the wake of reports from great deal of this meeting will be devoted Without Retinitis: Report of the Studies of Network are available to Academy mem- disgruntled LASIK patients. Malvina B. to discussions of treatments of exudative Ocular Complications of AIDS Research bers with their Academy username and Eydelman, MD, director of that FDA as well as nonexudative macular degener- Group password. group, will speak about her agency’s ation,” said M. Gilbert Grand, MD, a Reti- LASIK concerns. na Subspecialty Day program codirector. 6 f r i d a y G s a t u r d a y e d i t i o n
  • SUBSPECIALTIES He added that much of the AMD discus- uveitis, and in spite of all the publications out quickly.” But they guarantee side effects, OF INTEREST TO THE NONSPECIALIST. Much sion will focus on new methods for man- in peer-reviewed literature over the past so in the many instances in which the of the program is geared to the nonspe- aging AMD, particularly pharmacologic 25 years, “The vast majority of ophthal- uveitis is stubborn, the preferred practice cialist, said Dr. Foster, who hopes that by therapy, which has provided dramatic mologists around the world are stuck with is to move beyond corticosteroids. Experts day’s end the audience will understand improvement in achieving stability and just one string on the guitar—and that’s will discuss those practices. Also on the that the uveitis armamentarium contains sometimes even visual improvement. corticosteroids,” Dr. Foster said. agenda is a report on new drugs, including more than steroids. By early referral to an NEWS IN RETINA. Among the highlights The consequence of not heeding pre- intravitreal fluocinolone and an update ocular immunologist or chemotherapist are presentations on the use of ciliary ferred practices has led to needless disabil- on the Systemic Immunosuppressive trained to deliver novel treatments, or by neurotrophic factor to treat a number of ity and blindness, which will be covered in Therapy for Eye Diseases (SITE) study. teaming up with a specialist, we can reduce retinal diseases. Also in the lineup are pre- the talk “Prevalence of Visual Disability Quan Dong Nguyen, MD, codirector of the “shockingly disgraceful” prevalence of sentations of the results of studies using and Blindness: It’s a Disgrace!” the event, will review drugs in the pipeline. blindness from uveitis, he said. gene therapies to manage inherited retinal NEWS IN UVEITIS. “Steroids are wonder- There also will be an update on surgical Uveitis Subspecialty Day takes place on diseases, such as Leber’s congenital amau- ful,” Dr. Foster added. “They put the fire care of patients with uveitis. Saturday in Room A411. rosis. “Those are critically important papers,” Dr. Grand said. The agenda also includes retinal imag- ing, as well as a comprehensive review of management of choroidal melanomas and retinoblastoma. OF INTEREST TO THE NONSPECIALIST. “While the program is really designed for the retina specialist,” said Dr. Grand, “the Saturday afternoon session on uveitis promises to have universal appeal.” And for those interested in the history of ophthalmology, Harvey A. Lincoff, MD, a pioneer in the management of retinal detachment, will give a personal account of the evolution of retinal surgery, when he delivers the first annual Charles L. Schep- ens, MD, Lecture early Friday morning. “A great deal of effort has been made to include presentations that are clinically significant and on the cutting edge,” said Dr. Grand, adding that the hope is to pre- sent the most recent data regarding the current management of vitreoretinal dis- eases, including macular degeneration, hereditary retinal disorders, vascular occlusion, pediatric retinal abnormalities, diabetic retinopathy, uveitis and tumors.” Retina Subspecialty Day takes place on Friday and Saturday in the Hall A-3 Ses- sion Room. UVEITIS Maybe this year will be different. Maybe this year the message will sink in. The key message that C. Stephen Foster, MD, one of the directors of Uveitis Subspecialty Day hopes to deliver: “When treating idio- pathic or autoimmune-related uveitis, there’s a lot more out there than steroids.” Despite texts emphasizing the impor- tance of moving beyond corticosteroids, and courses given at the Academy on the Preferred Practice Patterns for treating RICHARD E. HACKEL, CRA, FOPS AMD TAKES THE DAY. Age-related macu- lar degeneration will command a large portion of the Friday agenda during Retina Subspecialty Day. e y e n e t ’ s a c a d e m y n e w s 7
  • THE LAUREATE THE ACADEMY HONORS A PIONEER IN RETINAL RESEARCH, TEACHING AND CLINICAL MEDICINE Alan C. Bird, MD, Named 2008 Laureate by gabrielle weiner, contributing writer T he Academy takes special pride in laboration with IO Professor Shomi Bhat- thy. He has worked in Jamaica recording honoring Alan C. Bird, MD—a tacharya, the team identified numerous the retinal changes in sickle cell disease world-renowned expert on the eye disease genes and cemented the stand- over a 21-year period using a rigorous treatment of retinal vascular disease and ing of the IO (which became a school of cohort generated by hematologist Graham genetic and degenerative retinal disorders University College, London) and Moor- Serjeant. Together, the team has docu- —as recipient of the 2008 Laureate Recog- fields Eye Hospital as one of the top eye mented the relatively benign nature of nition Award. research and care centers worldwide. sickle cell, thus obviating the need for Professor Bird has been one of the most Over the years, Professor Bird developed prophylaxis. prolific and innovative minds of the past a multidisciplinary and talented research Today, Professor Bird is involved in a 40 years in the field of medical retina. His team for studying monogenic retinal dis- number of important clinical trials. Most research has included the clinical and orders and age-related macular disease. recently, he chaired the Independent Data genetic documentation of families with Investigative techniques have included Safety and Monitoring Committee for the retinal disorders and the identification of molecular genetics, electrophysiology, pegaptanib (Macugen) trial for AMD. the genes responsible for those patholo- psychophysics, specialized imaging and “The development of biological treatment gies. This research has also led to the morphology. “In part because of the for choroidal neovascularization has been development of new technology to define tremendous clinical load and in part extremely exciting to watch,” he remarked. both the clinical characteristics of retinal because of the sophisticated level of sci- In addition to having worked with disease and the correlation of abnormal ence,” said Professor Bird, “the clinical the U.K.’s Medical Research Council and gene expression with metabolic dysfunc- and research activity at Moorfields and Wellcome Trust, the U.S.’s National Eye tion at the cellular level. the IO has attracted gifted post-residency Institute, France’s INSERM and Germany’s PROFESSOR BIRD is an internationally Born in London, Professor Bird received fellows from all over the world, many of Deutsche Forschungsgemeinschaft, Pro- recognized expert on the treatment of his medical degree from Guys Hospital, whom have made major contributions to fessor Bird is involved in advising industry retinal vascular disease and genetic University of London, where he trained in the field.” from a clinical perspective. Professor Bird and degenerative retinal disorders. both neurology and neurosurgery before With the help of two of his fellows from has earned the Duke-Elder, Doyne and his ophthalmic residency at Moorfields Germany, Professor Bird’s team was the Bowman medals in the United Kingdom from my colleagues at Moorfields and the Eye Hospital. He then had a one-year first to demonstrate that the accumulation and the Prix Chauvin in France. He has numerous fellows who were attracted to fellowship in neuro-ophthalmology at the of lipids in Bruch’s membrane was an inte- given numerous eponymous lectures the Institute of Ophthalmology in London Bascom Palmer Eye Institute in Miami gral part of AMD. “This was a concept that throughout Europe and North America from countries around the world.” and spent a brief period at the University derived originally from Dr. Dean Bok at and has received the Alcon Research In October 2005, Professor Bird retired of California, San Francisco. UCLA,” Professor Bird said. Along with Award, the Helen Keller Prize, the Paul from full-time clinical practice and was Professor Bird returned to London in the assistance of one of his fellows and Kayser Award and the Jules François appointed emeritus professor of medical 1969 and was appointed to the staff at the IO’s Professor Frederick Fitzke, Professor Medal. In 2006, he was honored by the ophthalmology at London University and Institute of Ophthalmology (IO) and Bird also developed a novel technique to Macula Society with a lifetime achieve- honorary consultant at Moorfields Eye Moorfields Eye Hospital, where he has document autofluorescence in the retinal ment award. Hospital. He and his wife, Sarah, have two remained ever since. In the late 1970s, he pigment epithelium for monitoring its “The essence of my career has been sons and one grandson, all of whom live established one of the first clinics in the health along with the health of photore- cooperative research between myself as in England. Professor Bird enjoys gardening world for inherited retinal disease. In col- ceptor cells. “For the first time, we record- a clinician and talented colleagues in the and playing golf when he can find time ed changes in disease involving the pig- laboratory who have been very generous and is an avid Rugby Union fan, rooting ment epithelium, something we had not in supporting clinically driven research,” for the London Wasps. He would want us PA S T AWA R D E E S been able to do prior to that time, at least said Professor Bird. “I have been so fortu- to mention that the Wasps recently won not accurately,” said Professor Bird. “We nate to receive constant and crucial support the 2008 Guinness Premiership Final. Every year, ophthalmologists distin- could not only look at drusen changes at guish themselves and the profession the level of Bruch’s membrane, but we by making exceptional scientific con- could also start observing changes in the WORDS FROM A FORMER FELLOW tributions toward preventing blindness pigment epithelium, an integral aspect of and restoring sight worldwide. The AMD.” I worked for Alan Bird in the early between basic retinal science and the board of trustees of the Academy rec- When asked what he feels is his greatest 1990s and have always felt it was clinic, and greatly enhancing our knowl- ognize these extraordinary contributions contribution to ophthalmology, Professor the most exciting year of my entire edge of retinal disease and therapies. with its Laureate Award, the Academy’s Bird doesn’t hesitate: “The most impor- ophthalmic training. Professor Bird is a caring and compas- single, highest honor. tant thing I’ve ever done was in river One of the things that made Professor sionate physician who is wonderful with blindness.” In the 1970s, he traveled to Bird special was his gift as both a clini- patients, never taking away hope from 2007 Africa to help a clinical team in Cameroon cian and a basic research scientist. With a the many patients with blinding retinal Claes H. Dohlman, MD with research. “The most notable finding detailed knowledge of basic retinal physi- diseases that have no treatment. 2006 was the identification that retinal and ology and molecular biology, he can speak As my teacher, “Prof” Bird—as we all Lorenz E. Zimmerman, MD optic nerve disease was the main cause of the language of the basic scientist while called him—was downright fun to work 2005 blindness rather than corneal scarring, providing critical analysis of findings from with and was always eager to share his Arnall Patz, MD and that the standard treatment of that the perspective of an astute and observant knowledge and passion for his work. And time—diethylcarbamazine—accelerated clinician. He has thus influenced the as a person, he’s simply a great guy, easy 2004 visual loss,” Professor Bird said. “This gave direction of research in retinal disorders, to relax and enjoy a good laugh with. Daniéle S. Aron Rosa, MD, PhD rise to the introduction of ivermectin as collaborating with some of the most influ- I’m very proud that I had the chance J. Donald M. Gass, MD the new treatment for onchocerciasis.” As ential retinal scientists of his time. to spend one of my most formative years Marshall M. Parks, MD a direct result, river blindness, which at Moorfields Eye Hospital has provided with Prof Bird. The 2008 Laureate Award 2003 the time was classified as one of the major him with a volume and variety of clinical is truly deserved. Charles D. Kelman, MD causes of blindness in the world, is now a pathology that few other institutions have Jack Wells, MD Robert Machemer, MD far smaller problem. had, and Professor Bird has not squan- Palmetto Retina Center, Charles L. Schepens, MD Another key achievement in Professor dered that opportunity, serving as a bridge Columbia, S.C. Bird’s career focused on sickle cell retinopa- 8 f r i d a y G s a t u r d a y e d i t i o n
  • TECHNOLOGY Birthday for a Beam of Light Happy 25! A Quarter Century of the Excimer Laser by annie stuart, contributing writer ablative photodecomposition to remove beg, borrow or buy a laser system from SUCCESS STORY. The excimer laser has found broad applications corneal tissue. him for further studies,” Dr. Trokel said. in many markets, from micromachining to medical uses. And no discipline has ULTRAVIOLET WORKS ITS MAGIC. Recogniz- Very soon, he and others would be doing ing its significance, Dr. Trokel reported in those studies. Animal experiments had been more dramatically altered by its advent than refractive surgery. Over the December 1983 American Journal of begun in Berlin in December 1983 and Ophthalmology, “The excimer laser, which would start shortly thereafter in the time, improvements in performance and reliability, combined with a host of produces light in the far-ultraviolet portion United States in the lab of Marguerite complementary techniques and innovations, have turned excimer refractive of the spectrum, allows precise removal of B. McDonald, MD, who was then at corneal tissue through a photochemical Louisiana State University. surgery into the most popular elective surgical procedure worldwide. laser-tissue interaction. This interaction is IDEAS FOR INITIAL APPLICATIONS. “The not thermal and does not involve optical earliest reports were to make cuts in the breakdown; rather, it directly breaks cornea to resemble RK,” said W. Bruce More than 800,000 Americans underwent laser in the mid-1970s. But its potential organic molecular bonds without tissue Jackson, MD, commenting on the work LASIK surgery in 2007, according to a for ophthalmic applications would wait heating.” of Thomas F. Neuhann, MD, and others. story published last April 24 in the Inter- until 1983, when Stephen L. Trokel, MD, The 193-nm, argon-fluorine excimer “And the second was to use it for thera- national Herald Tribune. That number was paid a propitious visit to photochemist laser energy was well absorbed by the peutic applications—such as for corneal an increase over 2006, although, as an elec- Rangaswamy Srinivasan, PhD, who was cornea, breaking organic bonds and eject- scars and even corneal infections,” he tive procedure, refractive surgery is subject using the excimer laser for microetching ing molecular fragments at supersonic added. “Then the concept came that you to the whims of a poor economy, and the computer chips at IBM’s Thomas J. Wat- speed. This ability was striking. could sculpt the cornea, actually take tis- Tribune story predicted a 17 percent drop son Research Center in Yorktown Heights, But what the laser didn’t do would sue off to correct myopia. That was really in patients this year, describing LASIK as N.Y. Dr. Trokel had also previously noted make it revolutionary: It did not cause the beginning.” Dr. Jackson is professor a barometer for economic recession. the work of John Taboada, PhD, who was significant mechanical or thermal injury and chairman of ophthalmology at the performing military safety testing of the to the cornea. “The experiments became University of Ottawa. FROM INKLING TO INNOVATION laser at low energy levels. Dr. Trokel subse- progressively more sophisticated as we HE DID THE MATH. Charles Munnerlyn, A RUSSIAN REVOLUTION. Scientists in Moscow quently oversaw a series of experiments systematically explored the laser tissue PhD, was curious about large-area abla- were credited with the design of the excimer on freshly enucleated bovine eyes, using interaction across the UV spectrum,” said tions and sought to do such experiments Dr. Trokel. “I had met with Dirk Bastings on rabbit eyes in 1984 with Dr. Trokel and Light micrographs, above, published by Dr. Trokel and colleagues 20 years ago in Oph- in August 1983 after a series of experi- Carmen A. Puliafito, MD, MBA. Then, Dr. thalmology, depict “a transversely sectioned cornea whose anterior surface has been ments.” (Mr. Bastings was then CEO of Munnerlyn started a project that resulted eroded to form a series of steps by exposure to an excimer laser through a progressively Lambda Physik, the manufacturer of the in construction of the first clinical proto- opening aperture.” excimer lasers.) “It was my intention to type photorefractive keratotomy (PRK) THE EXCIMER 1975 Early Russian develop- 1983 Stephen Trokel 1987 Theo Seiler performs 1991 Stephen Brint performs TIMELINE ment of excimer laser technology. describes use of excimer laser to remove first excimer treatment on a human eye. first LASIK procedure. corneal tissue (left). 1983 1988 Rangaswamy Srinivasan 1986 Marguerite McDonald uses excimer laser for Theo Seiler creates performs first excimer precise cuts in organic linear and arcuate PRK on a sighted materials. keratectomies for human eye (right). astigmatism. e y e n e t ’ s a c a d e m y n e w s 9
  • TECHNOLOGY CONTINUING CUSTOMIZATION my practice when wavefront was intro- A new generation of lasers allowed for duced—maybe 30 to 40 percent—and smoother surfaces, wider ablations and another huge jump with femtosecond better transition zones, all of which laser. These two improvements really improved corneal healing responses with resulted in a much larger segment of both PRK and LASIK, said Dr. Pallikaris. the population being willing to do laser It was possible to design almost any shape surgery.” of ablation profile of the cornea, including aspheric ablation profiles, first introduced THE LASER’S LONG REACH by Dr. Seiler in 1994. The future holds still more innovation for Dr. Trokel included this illustration in an essay he authored, “Evolution of excimer laser “Initially, we had no concept of how this laser: greater automated calibration, corneal surgery,” published in the Journal of Cataract and Refractive Surgery, July 1989. high a correction could be done or how improved beam profile, better trackers deep you could go in the cornea,” said Dr. and online pachymetry, to name a few. system. He worked out mathematically lasers, enabling greater accuracy of treat- Jackson. “We tended to use multizone-type And consensus about where to focus the the depth of ablation, diameter and edge ment and correction of higher-order opti- treatments, but they were small in diameter treatment—the visual axis or the pupil- angles, later cofounding Visx with Dr. cal distortions. “This made it possible to and often the patients ended up with more lary axis—may come at some point, as Trokel and Terry Clapham in 1986. create smooth, contoured ablations and glare, halos and other optical symptoms.” well as how best to integrate topography The ferment spilled over with the first customized patterns,” said Dr. Rabinowitz. But with automation, increased laser speed with wavefront. excimer treatment on a human eye by Ger- HALOS, HAZE AND GLARE. Optical side and larger treatment diameters, patient man ophthalmologist Theo Seiler, MD, effects such as glare, halo and contrast satisfaction started to go up,” said Dr. PhD, in 1987 and excimer PRK on a sight- sensitivity, and physical complications Jackson. ed human eye in 1988 by Dr. McDonald, were also challenging. Severe scarring or NEW TECHNIQUES HOP ON BOARD. To pre- who maintains the longest follow-up in haze indicated aggressive wound healing serve the epithelium, and reduce haze and the world. —either from epithelial healing over the pain, two other techniques evolved: laser ablated area or new collagen synthesis in in-situ epithelial keratomileusis (LASEK), EARLY OBSTACLES the superficial stroma—leading to regres- introduced by Dimitri T. Azar, MD, in As with any new technology, all did not go sion of effect. 1996, and a newer variation called epipolis smoothly at first. Two major challenges: Correcting optical problems was easier laser in situ keratomileusis (epiLASIK), controlling the laser’s beam and managing than addressing healing, noted Dr. Pal- an innovation of Dr. Pallikaris in 2004. surgical complications. likaris. “We were not familiar with the PATIENT, FIXATE THYSELF. Handheld fixa- NEEDED: BEAM CONTROL. The initial healing process of the cornea, so it took tion devices were replaced by self-fixation, pulse was delivered as a broad, rectangular a lot of time to observe and understand then, later, by a variety of pupil and limbus beam of irregular energy. To obtain con- the reason why we had so much haze and tracking devices. This allowed the excimer Schematic offered in a brief report on “Ophthalmic Excimer Laser for Corneal sistent clinical results, beam homogeniza- regression of myopia,” he said. “My initial system to compensate for saccadic move- Surgery,” published in March 1987, in tion and shaping were attempted through contribution in excimer laser history was ment and torsion, and brought an added the American Journal of Ophthalmology. various means. “It was difficult to control when I studied in the rabbit model nerve level of confidence to the patient experi- the size of the beam with the machine,” regeneration with gold chloride in order ence, said Dr. Jackson. said Ioannis G. Pallikaris, MD, director of to understand the healing process.” Mito- WAVEFRONT MAKES A BEACHHEAD. In What’s clear, however, is that the the Institute of Vision and Optics at the mycin C later came to the forefront as a March 1999, Dr. Seiler tried the first wave- knowledge accumulated because of the University of Crete in Greece. “So it was way to manage scar and haze formation front-guided PRK. Dr. Jackson described excimer laser has not only changed the helpful to use a masking procedure made following surface ablation. this as a leap forward. “All of a sudden we world of refractive surgery, said Dr. Jack- of apertures so we could ablate more in ADVANCING TO FLAPS. Dr. Pallikaris played were looking at patients who were 20/20 son, but had an amazing ripple effect in the center of the cornea and less in the another key role in mitigating the healing or 20/15, and even down to 20/10. In the many areas of ophthalmology. periphery.” challenges by developing the idea for laser old days, those would be numbers we Knowledge gained about how to man- To accommodate the need for expand- in-situ keratomileusis (LASIK) in the late wouldn’t even think of.” age dry eyes, ectasia or corneal scars all ing refractive indications, the masks used ’80s. “In 1990, I designed a prototype Treating without pupil centroid shift, had roots with the excimer experience. to shape the broad beam laser delivery microkeratome in order to generate the and employing torsional tracking—this “And when we got into aberrometry and were changed, said Yaron S. Rabinowitz, first corneal flap on a blind eye,” said Dr. all improved up results even more, added higher-order aberrations, this turned MD, director of ophthalmology research Pallikaris. Making precise flaps was a Dr. Jackson. cataract surgery around overnight.” Even at Cedars-Sinai Medical Center in Los challenge, he said, until automated micro- Today, most refractive surgeons use spectacles and contact lenses are affected, Angeles. keratomes came along to generate more wavefront systems, and, along with com- he said. “So it’s far-reaching in all our “For example, the axicon was used reliable flaps. FDA approval for LASIK puterized topography and aberrometry, optical corrections.” to rotate a decentered beam to correct occurred in 1999, four years following the wavefront-guided and optimized systems hyperopia,” he said, “which made that approval of the eximer laser for PRK cor- have provided new assurance with higher- Dr. Jackson is a consultant for AMO/Visx. Dr. application possible.” Over time, flying- rection of myopia in the range of 1.0 to order and induced aberrations, said Dr. Pallikaris reports no financial interests. Dr. Rabi- spot excimer lasers replaced broad-beam 7.75 D. Rabinowitz. “There was a huge jump in nowitz is a consultant for AMO and Wavelight. THE EXCIMER TIMELINE CONTINUED Cheers for a Quarter-Century of Argon-Fluorine Sculpting 1995 1999 2002 A Symposium to celebrate the 25th anniversary of the excimer laser will be held Sunday, FDA approves excimer FDA approves excimer FDA approves IntraLase from 10:45 a.m. to 12:15 p.m. in the Hall A-3 Session Room. For a schedule of speakers, search the Online Program for event code “Sym04,” or check your Final Program. laser to correct myopia laser for LASIK surgery. for laser-assisted cre- This Symposium will conclude with the 2008 Barraquer Lecture, “Corneal Surgery Is with or without astig- ation of corneal flap. Refractive Surgery,” delivered by Roger F. Steinert, MD. “We have made great strides in matism. 2000 replacing cloudy corneas with clear corneas,” said Dr. Steinert. “Yet our ability to FDA approves excimer 2004 achieve optically excellent corneas comparable to natural corneas has lagged seriously 1996 laser for LASIK to cor- Ioannis Pallikaris intro- behind this anatomic success. Meeting patients’ vision needs will involve borrowing the Dimitri Azar introduces rect hyperopia. duces epipolis laser in tools of refractive surgery, such as LASIK and PRK.” laser in-situ epithelial situ keratomileusis This is a combined meeting with ISRS/AAO and the European Society of Cataract keratomileusis 2002 (epiLASIK). and Refractive Surgery. Check your Final Program for many more presentations on the (LASEK). FDA approves wave- newest developments in corneal and refractive surgery. front-guided LASIK. 10 f r i d a y G s a t u r d a y e d i t i o n
  • R I S K M A NAG E M E N T OMIC work at Lessons Learned From Million-Dollar The courts, the cases, the verdicts Payouts by hans bruhn, mhs, senior risk management specialist, omic coma.) Instead, the ophthalmologist occa- 2. Decision-making process did not rule RISK EXPERTS. The Ophthalmic Mutual Insurance Company has sionally monitored the cup-to-disc ratio. out the worst-case scenario. been defending Eye M.D.s for 21 years. During this time, its indemnity Vision loss continued between 5.6 and 8.2 3. Patient was not responding to treatment. years, but this was thought to be due to 4. Recurring complaint. payments have tended to be significantly lower than those of other multi- exotropia. 5. New or evolving complaint. When the patient finally complained of 6. Repeat visits or phone calls. specialty carriers. This is due, in no small part, to OMIC’s governance by total vision loss, he was referred to a retina 7. Phone calls to multiple providers. ophthalmologists who understand the risks and worth of each case. specialist who found 100 percent cup-to- OMIC RESOURCES: Menke, A. M. Risk disc ratio with an atrophied optic nerve Management Issues in Failure to Diagnose (total vision loss) in the left eye and 65 Cases. This article discusses the diagnostic Recently, OMIC reviewed its claims both eyes and definite signs of macular percent cup-to-disc in the right eye. The process that was described above. (Avail- for the six subspecialties that are included vessel stretching in the right eye. patient is now on glaucoma medications. able at in this year’s Subspecialty Day to find On June 20, 2005, the insured declared ALLEGATION: Failure to diagnose open- the nine cases involving the biggest pay- that the patient was legally blind. angle glaucoma in a 3-month-old microph- RETINA : $1,500,000—failure to diag- ments, which ranged from $3,375,000 to ALLEGATION: Failure to diagnose ROP. thalmic infant after cataract surgery. nose choroidal melanoma. A 46-year- $800,000. Only one of these subspecial- DAMAGES: 20/370 in the right eye at 1 DAMAGES: Total vision loss (no light per- old man presented to an ophthalmology ties, uveitis, is not represented below. It foot and no light perception in the left eye. ception) in the left eye; 65 percent loss of group practice in January 1996 for a had a top payment of $500,000 (for a case EXPERT REVIEW: The defense and plain- vision in the right eye. routine eye exam and he was seen by an of endophthalmitis that resulted from a tiff experts felt that the ophthalmologist EXPERT REVIEW: The experts for both optometrist employed by the practice. dropped lens during cataract surgery). should have followed up with the patient the plaintiff and the defendant found that The optometrist identified a nevus on the By reviewing cases such as these, as much sooner than six months; he should the physician fell below the standard of patient’s right eye during that exam. The well as keeping an eye on trends within have had the patient return in two or care. IOPs should have been checked nevus was described as nonsuspicious, ophthalmology, OMIC is able to develop three weeks. There was an indemnity every six months. Following the cup-to- flat and about two discs in diameter. The very specific risk management recommen- payment of $3,375,000. disc ratio would only reveal whether dam- optometrist maintained that a photo was dations. (Many of these recommendations RISK MANAGEMENT ISSUES: The physician age already had occurred, and not all cup- taken of the nevus on this date, but no can be found on OMIC’s Web site, www. did not follow standard of care for exami- to-disc measurements were documented photo (or order to take one) was found in nation and treatment of ROP. In addition, in the file. Also, the retina specialist who the medical record. The patient was asked the hospital and the physician’s office didn’t saw the patient on referral from the origi- to return in one year for follow-up. PEDIATRIC OPHTHALMOLOGY : use a tracking system to ensure that the nal physician diagnosed marked glauco- Almost one year later, the patient returned $3,375,000—failure to diagnose child was examined within the proper matous cupping of the patient’s left eye to the office complaining of an inability retinopathy of prematurity. The patient time intervals. and stated that the vision loss in this eye to focus his right eye. He was seen by an was born via cesarean section on March OMIC RESOURCES: Menke, A. M. ROP was a result of chronic, long-term open- ophthalmologist in the group who sus- 23, 2003, at 26 weeks of gestation with a Creating a Safety Net. (Available at www. angle glaucoma. The case was settled for pected retinal detachment and referred birth weight of 960 g. An ROP exam was $1.8 million. the patient to a retina specialist. The spe- not done until May 7, at which point the RISK MANAGEMENT ISSUES: The physician’s cialist diagnosed a malignant melanoma baby was 6 weeks old and weighed 1,585 g. GLAUCOMA : $1,800,000—failure to diagnostic thought process failed to with overlying retinal detachment. The The ophthalmologist found no ROP, and diagnose open-angle glaucoma. A include a differential diagnosis for this patient was referred for treatment, but the plan was to follow up with another 3-month-old boy was diagnosed with patient. Both plaintiff and defense experts died in August 1999. ophthalmologist on Nov. 6. microphthalmia and bilateral cataracts. pointed out that there is a 15 to 20 percent ALLEGATION: Failure to diagnose However, before the follow-up appoint - Cataract surgery was performed. The increased risk of glaucoma in microph- choroidal melanoma. ment, the parents became concerned that ophthalmologist continued to treat the thalmic, cataractous patients. The physi- DAMAGES: Death. their child was not tracking well, and the patient for eight years but did not mea- cian may have avoided this misdiagnosis EXPERT REVIEW: The defense experts felt patient was seen on Aug. 19 by the insured. sure intraocular pressure every six months of open-angle glaucoma if he recognized the optometrist met the standard of care The ophthalmologist noted stage 4A ROP as is recommended for microphthalmic, the signs of a misdiagnosis: both in the follow-up duration (one year) OS > OD. The dilated funduscopic exam cataractous patients. (Such patients have 1. Diagnosis did not account for all symp- and in not needing a photo for a nevus of showed retinal detachment and fibrosis in a 15 to 20 percent increased risk of glau- toms and findings. this description. The plaintiff experts felt e y e n e t ’ s a c a d e m y n e w s 11
  • R I S K M A NAG E M E N T to turn the patient away but rather to of additional work life left with a decrease Atlanta: Booth and Special Events schedule the patient for an exam (because in earnings of approximately $150,000 per he was an ER patient). Poor follow-up on year. Also, past and future medical this patient contributed to the damages expenses were estimated at $100,000. and settlement of this case. EXPERT REVIEW: The plaintiff ’s experts OMIC RESOURCES: Menke, A. M. The stated that the residual stromal bed needed Ophthalmologist’s Role in Emergency Care: to be 250 µm or greater. The original On-Call and Follow-up Duties under physician fell below standard of care by EMTALA. (Available at failing to leave a margin of safety in this patient with borderline findings, both GLAUCOMA : $1,000,000—failure to before LASIK and again when a retreat- diagnose and treat glaucoma. An optom - ment was performed. This led to ectasia, etrist treated a 39-year-old woman for 10 requiring a corneal transplant. However, years. The patient regularly complained it was conceded that no surgeon in 2001 of decreasing, blurry vision. Nonetheless, reasonably could have predicted that the the optometrist did not perform any diag- patient would suffer from ectasia as a nostic tests and never referred the patient result of the LASIK. VISIT THE ACADEMY/OMIC INSURANCE CENTER. Chat with insurance experts who are to an ophthalmologist. The only response Defense experts could not support familiar with the full line of Academy-sponsored insurance programs. was to change the contact lens prescription. the care rendered. They opined that the Where. Hall B-4, Booth #3432. Indeed, the prescription appeared to be the patient had keratoconus and there were sole focus of the yearly visits. problems with the retreatment on the sec- OMIC ANNUAL MEMBERS MEETING. Timothy J. Padovese, president and CEO of OMIC, ALLEGATION: Failure to diagnose and ond eye because of what appeared to be will report on the company’s latest financial results. Plus, election of OMIC’s directors treat glaucoma in a 39-year-old woman. the first signs of ectasia. They also felt that and other business. DAMAGES: The patient ended up with the patient had progressive ectasia before When. Sunday, Nov. 9, 11:30 a.m. to noon, Room A304. Free. 100 percent cupping in both eyes with lit- the retreatment, increasing the likelihood OMIC FORUM: WRONG PATIENT—WRONG SITE—WRONG IOL. An in-depths review of OMIC tle optic nerve tissue remaining. she would need a corneal transplant in the claims will illustrate the faulty systems and practices that can cause surgical mistakes. EXPERT REVIEW: The optometrist failed second eye. Regardless, it was felt that a When. Sunday, Nov. 9, 1 to 3:30 p.m., Thomas B. Murphy Ballroom 1–3. Free. to conduct the required tests on this corneal transplant should be able to bring ULTIMATE CHART AUDIT. The AAOE’s “savvy coder” Sue Vichrilli, COT, OCS, and OMIC’s patient, and thus failed to meet the stan- the patient back to visual acuity in the risk manager Anne Menke, RN, PhD, will explain how improved documentation can dard of care. The ophthalmology practice 20/20 range. help you avoid both malpractice lawsuits and billing audits. also was named in this claim because it The case went to trial and the jury found When. Monday, Nov. 10, 9 to 11:15 a.m. A ticket for AAOE Instruction Course #358 employed the optometrist. Two insurance for the plaintiff 11-1. They awarded the costs $70 at Ticket Sales in Hall A-2. companies eventually settled the case, plaintiff a total of $944,420 before pre- with each company paying $500,000. judgment interest. RISK MANAGEMENT ISSUES: The primary RISK MANAGEMENT ISSUES: The ophthal- that the supervision of the optometrist given to follow up the next day with the risk in this case is that the optometrist mologist fell below standard of care with was inadequate; they argued that a consult ophthalmologist. However, the patient failed to diagnose glaucoma. When exam- this patient by performing the LASIK pro- with an ophthalmologist should have been was not able to set up a follow-up appoint- ining and treating this patient, he didn’t cedure despite contraindications for the done when the nevus was first detected. ment due to a miscommunication. The use a diagnostic process to rule out the procedure. The case was settled for $1,500,000. The ophthalmologist’s office had a policy not worst possible diagnosis. The optometrist optometrist and the group were separately to treat patients on public assistance, failed to consult with others in the prac- REFRACTIVE SURGERY : $900,000— insured; the group paid $500,000 due to except if they are ER follow-up patients. tice to determine the cause of the patient’s contraindicated LASIK. On Dec. 1, 2003, its vicarious liability as the employer. The ophthalmologist failed to instruct his loss of vision. The secondary risk here is the ophthalmologist first saw a 47-year- RISK MANAGEMENT ISSUES: It would have office that this patient should be sched- that the employer (the group practice) old woman who expressed interest in been prudent for the optometrist to refer uled for an appointment, nor did he may not have properly supervised the LASIK. She had a history of myopia with the patient to the ophthalmologist when instruct the patient to mention this excep- optometrist. astigmatism. She was also presbyopic and the nevus was first detected. Consider tion to the group’s scheduling staff. Three had been wearing contact lenses for many advising employed optometrists to refer days later, treatment for a corneal ulcer REFRACTIVE SURGERY : $983,000— years, and monovision contact lenses patients with a new finding of nevus for a was provided by other providers. The negligent LASIK. On Dec. 5, 2001, a 48- more recently to treat her presbyopia. consultation with the ophthalmologist. patient had serious opacity in the right year-old woman had bilateral LASIK. On Her previous prescriptions for glasses was Owing to the vicarious liability that the eye and the possible need for a corneal day 1 postop, her visual acuity was 20/25 two years old. group practice has (and its easy referral transplant. in the right eye, 20/30 in the left. One Visual acuity with correction was capability), protocols should have been ALLEGATION: Failure to treat a corneal month later, the patient’s visual acuity noted as 20/40 in both eyes. Pachymetry developed requiring referral in cases such ulcer. was 20/50 in both eyes. readings taken by staff were 485 µm and as this. DAMAGES: The patient’s eyesight in his On June 19, 2002, a retreatment on her 462 µm in the right eye, and 462 µm and OMIC RESOURCES: Menke, A. M. Coman- right eye has been measured 20/40 or bet- right eye was performed, followed by a 471 µm in the left. Pupil size was 6 mm in agement of Ophthalmic Patients. (Avail- ter, but ongoing treatment indicates the retreatment on her left eye on July 18. It both eyes. The ophthalmologist discussed able at possibility that his eyesight may worsen should be noted that the insured did dis- the risks and benefits of LASIK and PRK. and a transplant may be needed. His left cuss with the patient the increased risks The patient elected to have LASIK. CORNEA/ EMERGENCY MEDICINE : eye is unaffected. due to her thin corneas. Four months On Dec. 4, the procedure was per- $1,000,000—failure to treat corneal EXPERT REVIEW: Although the treating later, the physicians referred the patient formed on both eyes. Postoperatively, ulcer. In March 1994, a 2-year-old male ophthalmologist followed the standard of to another ophthalmologist for a second the patient complained of headaches and patient fell into an “oily, dry matter” on care for this patient, defense experts felt opinion since the patient continued to be continued blurriness. Two weeks later, his family’s driveway. Shortly thereafter, the group’s practice of not seeing public dissatisfied with her results. In May 2003, the ophthalmologist refloated the flap. the patient complained of something in assistance patients would not reflect well after a diagnosis of keratoconus and ecta- Afterward, the patient complained of star- the right eye, and his mother noted drain- on a jury should the case go to trial. The sia, this physician did a corneal transplant bursts and ghosting. Visual acuity after age. The patient went to a local emergency case was settled for $1,000,000. on the patient’s left eye. He stated that on the refloat was recorded as 20/40 + 3 and room for treatment that same day. The RISK MANAGEMENT ISSUES: The ophthal- Oct. 28, he was planning to proceed with a 20/50 in the right and left eyes, respec- ER doctor called the ophthalmologist to mologist did not properly document the corneal transplant on the right eye. tively. The physician recommended a discuss the case. The ER notes indicate treatment that he phoned in to the ER ALLEGATION: Negligent LASIK. retreatment procedure, which the oph- corneal abrasion with acute inflammatory physician. He should have made a note of DAMAGES: The patient was making thalmologist performed nine months response. A patch was placed on the eye the patient’s name and the fact that he was $250,000 a year before her surgery and later. The patient then complained of with ointment, and instructions were on public aid and also alerted his staff not $90,000 a year afterward. She had 15 years foggy vision and ghosting, especially in 12 f r i d a y ● s a t u r d a y e d i t i o n
  • R I S K M A NAG E M E N T the left eye, and continued to have prob- mologist’s preoperative assessment of this lems with astigmatism. A toric lens was patient was incorrect. Topography findings Malpractice Rates Continue Falling prescribed. In June 2006, the patient and the patient’s thin corneas should have P expressed concerns about LASIK and strongly ruled out LASIK. hysicians have experienced a by state and averaging nearly 22 percent decrease of vision in both eyes. The oph- respite from rising malpractice during the same three-year period. thalmologist noted in the medical record, REFRACTIVE SURGERY : $850,000— insurance costs in recent years with Since 2000, OMIC has outperformed “corneal ectasia OU s/p LASIK OU and contraindicated PRK. On May 23, 2005, premiums falling in many regions of the multispecialty carriers, and it credits this enhancements OU.” The patient was the patient was evaluated by one ophthal- country. Most industry experts expect the to two factors: the favorable risk profile of referred to another ophthalmologist who mologist in the practice and was noted to good news for doctors will continue for ophthalmologists compared with physi- diagnosed ectasia, noting a pattern that be a good candidate for LASIK. Pachyme- another year or two as insurance carriers’ cians in other specialties plus its focused was consistent with pellucid marginal try revealed a corneal thickness of 474 µm balance sheets remain relatively strong underwriting and risk management philos- degeneration. He recommended that the in both eyes. The patient had a corrected due to better underwriting results. ophy. OMIC has been at or near the top of patient try a postrefractive surgery reverse visual acuity of 20/30 but could not be Although claims related to retinopathy the list of physician-owned carriers in the geometry lens. The physician reported corrected to 20/20 with glasses. Topogra- of prematurity have emerged as a concern United States when measuring combined back to the referring ophthalmologist that phy was done, but the medical record due to the potential for large losses, oph- and operating performance ratios. Some he “discussed with her the possibility that a shows no interpretation. thalmology is, in many instances, faring observers opine that OMIC’s strong results corneal transplant may be necessary if she On Aug. 3, the patient returned and better than other specialties. during the difficult market conditions a feels that her vision is inadequate with was seen by another ophthalmologist, The largest carrier in ophthalmology, few years ago prompted the shift from glasses and if she does not tolerate contact and it was this second physician who was OMIC, implemented large policyholder multispecialty programs. lenses.” He found visual acuity with her named in the case. During this visit, the dividend returns totaling more than 35 Learn more about OMIC. Talk to OMIC existing glasses to be 20/60 in the right corneal thickness was noted as 473 µm percent over the past three years in addi- representatives at the Academy/OMIC eye and 20/50 in the left. in the right eye and 442 µm in the left. tion to significant rate decreases varying Insurance Center (Hall B-4, Booth #3432). An OMIC review of the claim found Topography was repeated without any the LASIK procedure was contraindicated comment on the findings. Uncorrected had experienced a severe complication coagulation in his left eye with indirect due to abnormal topography as evidenced visual acuity was 20/400 in the right eye known as corneal ectasia. The resulting laser and pars plana vitrectomy with endo- by asymmetrical inferior steepening and and 20/200 in the left. The patient signed decrease in visual acuity made it impossible laser in his right eye. Prior to surgery, the abnormal corneal irregularity measure- a LASIK consent form at that time. The for the patient to drive or work, and the ophthalmologist noted proliferative dia- ment on the Humphrey greater than 1.0. patient was warned of the risks of operat- ophthalmologist stated that the patient betic retinopathy with vitreous hemor- In addition, the patient’s corneal thickness ing on both eyes at the same time, but he was totally disabled. On Sept. 6 and 7, the rhage in both eyes. The patient underwent was 0.480 OD and 0.460 OS, which is also clearly expressed a desire to have both eyes ophthalmologist fitted the patient with peribulbar injection in the right eye and abnormal. The patient did not do well done at the same time. special lenses to combat the weakened intravenous sedation. However, both pro- postoperatively, and the insured com- On Aug. 12, the ophthalmologist sug- cornea. On Sept. 14, the ophthalmologist cedures were interrupted by a cardio- pounded the problem by doing bilateral gested the patient undergo PRK instead of documented corrected vision of 20/60 in pulmonary event. Intravenous sedation retreatments even though topography LASIK due to pachymetry and topography. the right eye and 20/50 in the left. However was given by the anesthesia staff (CRNA), was even more abnormal and refraction No specific PRK consent form was signed. the patient could not tolerate the contact who used 4 mg of midazolam and 100 µg showed loss of BCVA. The ophthalmologist signed off on the lenses in spite of trying several pairs of fentanyl. The patient became unrespon- ALLEGATION: Contraindicated LASIK in LASIK consent and proceeded with PRK. specifically ordered to deal with ectasia. sive. While 911 was called, the CRNA intu- the right eye. On Aug. 13 (day 1 postop), the patient On Dec. 28, when the patient visited the bated the patient with an endotracheal DAMAGES: Lost wages claim of approxi- was doing well with UCVA of 20/100 in ophthalmologist for the last time, visual tube and maintained respiration with an mately $400,000 and a potential for higher both eyes. However, by Aug. 15 (day 3 post- acuity with contact lenses was 20/200. ambubag with oxygen at the maximum award due to significant medical issues op), UCVA was 20/50 and the patient ALLEGATION: PRK contraindicated by level. A stethoscope was used to confirm with the physician. complained of blurry vision, which was topography. Improper informed consent. the endotracheal intubation. EMS arrived EXPERT REVIEW: The defense expert was worse in the right eye than the left. DAMAGES: Loss of future earnings, which and took charge of cardiopulmonary not able to support the case. He opined On Aug. 19, UCVA decreased to 20/200. is reflected in the settlement of $850,000. resuscitation, later noting that the initial that the preoperative corneal topography, The ophthalmologist noted corneal haze, EXPERT REVIEW: The plaintiff ’s expert intubation was not successful (the tube showed inferior nasal steepening and greater in the right eye than in the left. also was the subsequent treater and had was in the esophagus). The patient was oblique astigmatism, indicating form When seen on Aug. 23 and 25, the patient considerable credibility as a witness. He eventually admitted to the hospital, where fruste keratoconus. In addition, the was doing better but UCVA had not opined that the patient had keratoconus he was diagnosed with anoxic encephal- patient had thin corneas. Retreatment improved. On Aug. 29, the insured wrote in the left eye and form fruste keratoconus opathy with secondary myoclonic jerking. made her ectasia worse. a letter to the patient’s disability insurance in the right eye. He believed the ophthal- The patient died two months later. The case was settled for $900,000. carrier that stated the patient had under- mologist violated the standard of care for ALLEGATION: Vitrectomy, negligent RISK MANAGEMENT ISSUES: The ophthal- gone an uneventful PRK procedure but PRK on the left eye, but he conceded form resuscitation resulting in death. fruste keratoconus is not an absolute con- DAMAGES: Death traindication to PRK. He also said that the EXPERT REVIEW: Experts for both the More Online patient never should have undergone PRK plaintiff and the defense felt that the in both eyes simultaneously. negligence in this case centered on the The defense experts could not support anesthesia care as well as response to the O MIC provides a rich array of resources comanagement; documentation and record for physicians at keeping; patient relations; managed care; the physician’s decision to proceed with cardiopulmonary event. The case was ulti- These include risk management and advertising and marketing. surgery in the face of the topography. mately settled for $800,000 because it was recommendations that feature detailed The OMIC Web site also provides many Also, they believed that it would be diffi- thought that there was less than a 50 per- analysis of many important liability risks subspecialty-specific consent forms (includ- cult to defend the informed consent issue. cent chance of a defense verdict for the faced by practicing ophthalmologists. ing some in Spanish) as well as patient RISK MANAGEMENT ISSUES: If there is a ophthalmologist. This information minimizes the risk of safety advisories for use in a physician’s change in procedure, the patient’s informed RISK MANAGEMENT ISSUES: During cre- patient harm and reduces the likelihood medical office. consent process must be redone and doc- dentialing, ensure that the CRNAs have of allegations of professional liability. OMIC also offers an array of online risk umented. Also, the topography skills of current competency in situations without Physicians can browse the OMIC publi- management courses for ophthalmologists the surgeon must be current. backup. Consider calling 911 if a patient’s cation archives, which feature dozens of who are unable to attend live seminars OMIC RESOURCES: Menke, A. M. Obtain- condition deteriorates. And ensure that articles in the following 11 categories: and audioconferences. These interactive ing and Verifying Informed Consent. (Avail- the physician and staff have current train- ophthalmic clinical risk management; courses allow physicians an alternative able at ing in Basic Life Support for health care closed claims studies; policy issues; gen- method to earn CME credits and an OMIC providers. eral office risk management; litigation risk management premium discount on RETINA : $800,000—negligent resusci- OMIC RESOURCES: Menke, A. M. Anes- and claims handling; informed consent; their professional liability policy. tation. A 45-year-old male patient was thesia Liability. (Available at www.omic. scheduled to undergo a panretinal photo- com.) e y e n e t ’ s a c a d e m y n e w s 13
  • RESOURCES Are you taking advantage of the Academy’s array of resources? The Academy Resource Center will help you build and maintain a flourishing practice. VISIT THE ACADEMY Resource Center INVEST IN YOUR FUTURE TODAY FIND IT FAST this tool for giving educational and train- ing presentations to nonophthalmic physi- ficient in examining the anterior segment. The book also includes a DVD of video The Academy Resource Center (Hall B-4, Booth #3532) is designed so that cians and health care professionals. The clips demonstrating basic and advanced CD-ROM also features a library of clinical gonioscopic techniques. you can swiftly find what you need. Kiosks are clearly labeled (see map), images, text slides and speaker notes. and Academy staff are on hand at the Information desk and throughout the CME REPORTING CLINICAL EDUCATION : O.N.E. To report your Atlanta CME, either type it in exhibit to help you zero in on the resources that will be most useful for your Check out the Ophthalmic News & Edu- at a CME Reporting/Proof of Attendance cation (O.N.E.) Network, the Academy’s kiosk or fill out your Final Program’s CME practice. If you only have a couple of minutes to spare, head straight for the comprehensive online educational portal, form, which you can drop off at the Mem- New Products display. which enhances your ability to access rele- ber Services desk or mail to the Academy. vant clinical information from an extensive knowledge base. O.N.E. saves you time by ETHICS ACADEMY STORE Online is also available. You can access combining a suite of educational tools Visit the Maintenance of Certification Enjoy a 10 percent discount when you all 13 sections from any computer with with aggregated clinical content from a kiosk to see a live demo of the Academy’s place an order of $250 or more at The an Internet connection. This online for- variety of trusted sources. three free online ethics courses and to Academy Store. Most products are avail- mat confers password-protected access, download MP3s of the same courses. able to be picked up today, or you can have enhanced search capabilities and user- CLINICAL EDUCATION: PRINT Information about other ethics program your order shipped back to your office. friendly features. View the Academy’s latest clinical educa- offerings will be available at the Member I Front Row View: Video Collections of tion print media: Services desk where staff are available to ADVOCACY Eye Surgery. Watch up-to-date video clips I BCSC. The 13 volumes of this year’s answer questions. The Federal Affairs & OphthPAC desk of surgical procedures. Basic and Clinical Science Course include is the place to be to send a letter to your I Clinical Skills Video Series. Take a look four major revisions—Section 10: Glau- EYESMART AND COMMUNICATIONS members of Congress on issues of impor- at demonstrations of the clinical skills coma; Section 11: Lens and Cataract; Sec- Check out the EyeSmart desk to catch up tance to ophthalmology. You also can speak needed across several disciplines of oph- tion 12: Retina and Vitreous and Section on the Academy’s public awareness cam- to experts on Medicare reimbursement thalmology. 13: Refractive Surgery. paign and other media-related activities. and regulatory issues, and you can make I The Video Atlas of Eye Surgery Series I Focal Points. Stay up to date with a I EyeSmart. This year’s focus is prevent- a donation to OphthPAC. —Phacoemulsification: 3. Complications, subscription to Focal Points: Clinical ing eye injuries. Learn more about the Go to the State & Subspecialty Relations Discs 1, 2 and 3. Browse the latest volumes Modules for Ophthalmologists. Available campaign’s efforts at the EyeSmart desk desk to find out how the Academy is work- of this video-based training program. Top- in online and print versions. and ask how you can get involved. Sign ing with state and subspecialty societies. ics include local anesthesia, capsulorhexis, I ProVision: Preferred Responses in up to receive free educational materials Ask about optometric scope of practice hydrodissection, wound burn and cham- Ophthalmology. Assess your ophthalmic (available to U.S. members) and pick up and the Surgical Scope Fund. ber-shallowing techniques. Surgical knowledge and stay current on a range of a free EyeSmart gift. videos are supplemented with custom- clinical issues with a two-volume set that I Media Relations. View a tape of the top CLINICAL EDUCATION: CD-ROMS AND built graphics and 3-D animations. Each contains 450 questions and discussions in ophthalmology stories in the mainstream DVDS volume is sold separately and is available nine subspecialty areas, including the news from the past year featuring your View the Academy’s latest clinical education for purchase online as streaming video. rapidly changing field of keratorefractive colleagues, and sign up to become a clini- digital media: I LEO Clinical Update Course. Click surgery. Featuring the same content as the cal correspondent yourself. I BCSC. The CD-ROM set includes through DVDs in the Lifelong Education print series, the online version offers the BCSC Sections 1–13. You can search, write for the Ophthalmologist Clinical Update capability to access the self-assessment MAINTENANCE OF CERTIFICATION notes, highlight text, bookmark important Course series, including the latest titles, questions and discussions online. The MOC Exam Study Kit is available sections and link to PubMed references. Orbit and Ophthalmic Plastic Surgery and I Color Atlas of Gonioscopy. Browse online through the O.N.E. The kit—an Special discounts are available for CD- Pediatric Ophthalmology and Strabismus. through the second edition of the text Academy member benefit—includes com- ROM/print combination orders. BCSC I Eye Care Skills CD-ROM. Check out designed for clinicians wishing to be pro- prehensive study outlines, study questions 14 f r i d a y G s a t u r d a y e d i t i o n
  • and timed exams for 10 practice emphasis areas and Core Ophthalmic Knowledge (a required DOCK exam module). Ask to see THE ACADEMY RESOURCE CENTER a live demo at the Maintenance of Certifi- HALL B-4, BOOTH #3532 cation (MOC) kiosk. MEMBER SERVICES Visit the Member Services desk to peruse the 2008–2009 Member Directory; drop off your CME form; pay dues; update your phone, fax, address, e-mail or bio- graphical information; pick up an appli- cation form for ISRS/AAO or AAOE; and get information on the awards program. PATIENT EDUCATION Explore the latest Academy’s patient edu- cation materials: I Patient Education DVDs. Check out the updated Understanding Age-Related Macular Degeneration DVD, which explains nonproliferative and proliferative diabetic retinopathy from both the physi- cian’s and patient’s perspectives. Also peruse the revised Understanding Diabetic Retinopathy DVD featuring real AMD patients discussing their experiences with the disease and physicians discussing diag- nosis and treatment options. Both DVDs include a Spanish-language option. I Patient Education print media. Take a look at the latest offerings, including the Endothelial Keratoplasty (EK) and Laser Trabeculoplasty brochures, the Enhanced Lens Options for Cataract Surgery booklet and the BPH Medications and Eye Surgery eye fact sheet. I DVD Personalization Booth. Add your own on-camera introduction to an Acade- my DVD. I Digital-Eyes Ophthalmic Animations for Patients and Personal-Eyes CD-ROM Set. Check out the Academy’s Digital-Eyes Ophthalmic Animations for Patients CD- ROM, featuring a collection of more than 40 high-quality animated segments show- ing and discussing a wide variety of eye PRACTICE MANAGEMENT/AAOE Know to Operate a Profitable Dispensary. anatomy and treatment topics. Also see Want to know what reference and training Discover the practical aspects of opening AND WHILE YOU’RE HERE... the Personal-Eyes CD-ROM, featuring resources are available? Have your ques- an optical dispensary and operating it at Take a moment to visit the neighbor- more than 200 customizable patient edu- tions answered at the following kiosks and peak profitability. ing exhibits: cation handouts. help desks: Foundation of the American Academy I PowerPoint. See the Academy’s patient I AAOE Practice Management Center. QUALITY OF CARE & KNOWLEDGE BASE of Ophthalmology (BOOTH #3440) education PowerPoint collections, designed Get advice from practice management Browse through the Academy’s Preferred This public service foundation is dedi- to help you make complete presentations experts (appointments are recommend- Practice Patterns and Summary Bench- cated to reducing avoidable blindness to patients, community groups, nonoph- ed) and browse through the entire prod- marks. You can download the Bench- and severe visual impairment. thalmic medical professionals and others. uct line of the AAOE. marks onto your PDA at the Quality of I Coding & Reimbursement desk. Care & Knowledge Base desk and the Museum of Vision (BOOTH #3440) PERIODICALS Browse the ICD-9 for Ophthalmology; Technology Pavilion (where it is also Visit “Eye Seeing Eye: Art and Ophthal- Visit the Academy Periodicals desk to ICD-9 Quick Reference Cards; the CPT available in a BlackBerry format). mology” to explore the crossroads of art learn about the Academy’s informational Standard and Professional Editions; the Remember to ask about the new Oph- and medicine. The exhibit showcases resources. HCPCS manual; the CPT Pocket Guide for thalmic Technology Assessments: Anti- the museum’s unique collection of I Academy Express. This e-newsletter Ophthalmology; as well as Code This Case VEGF Pharmacotherapy for AMD; Safety works specifically devoted to ophthal- offers highlights from peer-reviewed clini- and the Ophthalmic Coding Coach book of Overnight Orthokeratology for Myopia; mology and sight. It also explores how cal journals, opinions from leading experts and CD-ROM. Find out about the latest Wavefront-Guided LASIK for the Correc- art movements have influenced the in the field, as well as news from the Acad- modules in the Ophthalmic Coding Series tion of Primary Myopia and Astigmatism; design of diagnostic and surgical instru- emy and your regional ophthalmic society. and the Ophthalmic Coding Specialist Aqueous Shunts for Glaucoma; and ments, inviting viewers to appreciate Academy Express is e-mailed to ophthal- Exam Flash Cards. Orbital Radiation for Graves Ophthal- these artifacts like works of fine art. mologists around the globe every week. I A+ Marketing: Proven Tactics for Suc- mopathy, as well as newly revised PPPs: The Academy/OMIC Insurance Center I Ophthalmology and EyeNet. Check cess. Learn how to identify cost-effective Age-Related Macular Degeneration; Bac- (BOOTH #3432) out the Academy’s highly esteemed peer- marketing opportunities for you practice. terial Keratitis; Blepharitis; Conjunctivitis; Consult with insurance experts familiar reviewed journal and news and clinical This book contains ideas, action plans and Diabetic Retinopathy; Dry Eye Syndrome; with the full line of Academy-sponsored update magazine. examples from successful practices. Idiopathic Macular Hole; and Posterior insurance programs specially designed I The Web site. Drop by and offer your I Dispensing for Ophthalmologists— Vitreous Detachment, Retinal Breaks, and for ophthalmologists. feedback on What MDs and Administrators Need to Lattice Degeneration. e y e n e t ’ s a c a d e m y n e w s 15
  • AQUATIC EYES At the Join Your Colleagues for Some Visual Surprises Aquarium Five Galleries and 500 Different Species by ivan r. schwab, md A WORLD OF WONDER. During the opening hour of Sunday’s Orbital Gala you’ll have the chance to explore Atlanta’s spectacular aquarium, the largest in the United States. You’ll find animals—some common, some not-so-common—that must interact with the world visually. And as ophthal- mologists, we are prone to wonder, “Just how do these animals see?” The aquarium is divided into five galleries: Georgia Explorer, River Scout, Cold Water Quest, Ocean Voyager and Tropical Diver. All of these are filled with wonderful surprises, with each specimen having its own interesting story. Here are just a few examples. IN THE GEORGIA EXPLORER GALLERY—possi- bly the oldest extant compound eye. The horseshoe crab has been with us for more than 500 million years and has changed little during that time. It boasts the largest ommatidia (individual eye facets) of any animal, and it has approximately 1,000 of these ommatidia in each of the two lateral eyes. Look for the two visible median eyes The Horseshoe Crab witnessed the rise at the front of the carapace. Now look for and fall of the dinosaurs. You can get tac- the small eyes immediately behind the lat- tile with this living fossil at the aquarium’s GEORGIA AQUARIUM eral eyes; these “extra” eyes are for circadi- touch pools (Georgia Explorer gallery). an rhythm. The horseshoe crab has a total of 10 eyes if you count the eyes on the charge of direct current their lenses devel- ventral surface! It even has photoreceptors op just a bit more cataractous change. lining its tail. Older eels will have dense cataracts from The species has helped researchers these repeated shocks. However, these THE ACADEMY FOUNDATION’S ORBITAL GALA takes place on Sunday, from 5 p.m. ’til late at the understand visual processing. Because it cataracts won’t diminish an eel’s hunting Georgia Aquarium. Enjoy a private viewing of the aquarium’s specimens until 6 p.m., when the has very large nerves transmitting images skills because it relies mostly on sensory main exhibits area will close. At 6 p.m., head upstairs to the ballroom for dining, dancing and— from those very large ommatidia, it was mechanisms other than vision. new this year—a silent auction. Need tickets? Tickets cost $300 each, and a limited number an early subject in the study of vision. IN THE COLD WATER QUEST GALLERY — may still be available on a first-come, first-served basis. To check availability, visit the Estate IN THE RIVER SCOUT GALLERY —eyes with eyes that could put the retina surgeon and Planned Giving Office in Room A406-407 of the Convention Center on Saturday (8 a.m. to electric cataracts. Electric eels use their out of business. If you get a chance, go see 2 p.m.) or Sunday (8 a.m. to 1 p.m.). shocks to subdue prey, but with each dis- the octopus. There are many intriguing e y e n e t ’ s a c a d e m y n e w s 17
  • AQUATIC EYES blood in sea water at concentrations as low as one part per 25 million. For ophthalmologists, an interesting footnote to the unusual morphology of its head is that the optic nerves extend a foot or more from the eye to the brain. IN THE TROPICAL DIVER GALLERY —eye of a predator. Depth perception is critical when hunting prey, but how do fish achieve adequate stereopsis if their eyes are posi- The Electric Eel’s unusual hunting technique can have shocking repercussions for tioned on the sides of their head? Some its visual health (River Scout gallery). intriguing evolutionary adaptations have solved this problem, as illustrated by the aspects to this fascinating species. Think, IN THE OCEAN VOYAGER GALLERY —the Koran angelfish. Like most predatory fish, The Giant Pacific Octopus employs a for instance, about their visual system. nose that knows. Sharks are invariably it has a horizontally oval pupil. This pupil sharp visual acuity, along with remark- They have an odd horizontal pupil that among the most popular exhibits at an is pear-shaped, with the apex of the “pear” able intelligence, when hunting its prey can close virtually completely, like window aquarium, and the hammerhead shark pointing toward the nose. When examin- (Cold Water Quest gallery). blinds. The retina is everted, meaning that arouses an additional fascination due to ing these fish, you will see the edge of the the photoreceptors point toward the lens. the peculiar shape of its head. What evo- lens in the pupil’s periphery. The space field of vision, and what the shark per- There are no intervening amacrine, hori- lutionary advantage did this give it? anterior to the edge of the lens is known ceives is gray. The colorful fish simply zontal or ganglion cells. Hence, there is The hammerhead family emerged as as the aphakic space. Now, if you look blend into the background. If the fish no blind spot and no chance of a retinal an evolutionary anomaly more than 24 head-on at that fish, you can see that the were a single color, they would stand out detachment. million years ago. The unusual shape of its aphakic space permits the image to tra- against the reef, but “gray” fish blend in. But the really intriguing aspect of an head allows for improved electroreception verse the lens to the periphery of the reti- NOT GOING TO THE ORBITAL GALA? If you’re octopus’ vision is this: Octopi can change and stereo-olfaction. Hammerheads can na where the fovea resides. If the pupil not able to attend the Foundation’s Orbital colors in response to threats or when compare an odor from one side of its head were round, the edge of the pupil would Gala but still want to visit the Georgia hunting but, surprisingly, they are color to the other, and as they swim you’ll see interfere with the transmission of light to Aquarium, you can go online at www. blind and have only one visual pigment them swing their heads from side to side the fovea. In other words, the aphakic for current hours of with peak absorption at approximately to make the most of this ability. They also space permits this fish to be stereoscopic. operation and to book tickets. You also 475 nm. How does this work? No one have among the largest olfactory bulb-to- Note that this eye continues to grow can purchase tickets by calling 404-581- knows. brain ratios of any species and can detect throughout life and that should move the 4444. This popular attraction is some- fovea toward the posterior pole. But that times filled to capacity, so advanced book- doesn’t happen because there are retinal ing is highly recommended. stem cells at the periphery of the retina. The Georgia Aquarium is located in IMPROVE YOUR PRACTICE’S EFFICIENCY These stem cells continually supply the downtown Atlanta at 225 Baker St. NW, eye with enough photoreceptors to permit across from Centennial Olympic Park. I t’s a reality that 80 million Baby Boomers the retina to continue to grow, keeping the will begin to retire over the next few fovea in the same topographical location. years. Since many eye diseases are relat- Bright shades of gray. The coral reef ed to aging, ophthalmologists will play a exhibit can be mesmerizing, with sleek particularly important role in the health care colorful fish and beautiful corals. But did of this population. And yet the number of you ever wonder why the fish are so color- ophthalmologists is not expected to increase ful? Wouldn’t it be counterproductive and over the next 20 years. The combination of even dangerous to call attention to oneself these facts points to heavier patient loads with all these colors? Many of these fish for ophthalmologists in the near future. are bathed in complementary colors. A higher patient-to-provider ratio can be When viewed at close range, these bright a blessing for those physicians who run very colors are important for communication efficient practices. While it takes some fore- and mating. But when viewed from a thought and commitment to develop and implement a plan for improving practice effi- The Koran Angelfish enjoys binocular “patrolling” distance—as when, for ciency, it is well worth the effort for Eye M.D.s and the patients they serve. At the Joint vision despite its eyes being on the side instance, a shark is cruising the reef— Meeting, there are 10 sessions to get you started thinking about how to ramp up your of its head (Tropical Diver gallery). these colors come together in a receptive practice’s efficiency: Time Management for Managers Monday, 10:15 to 11:15 a.m., in Room Meet the Expert Event Code 216, $35, Sunday, 2 to 3 p.m. #B303. If you don’t have a chance to chat with Dr. Schwab during Sunday’s Orbital Gala, you Using RVUs to Manage Your Practice Physician Productivity: Maximizing It With can attend one of his Instruction Courses. Event Code 217, $35, Sunday, 2 to 3 p.m. Systems and Staffing Evolution’s Witness takes place on Monday from 9 to 10 a.m. Although visual devel- Conquering Patient Flow Problems Event Code 461, $35, Monday, 4:30 to opment probably began in the Precambrian period, it was the Cambrian explosion that Event Code 250, $70, Sunday, 3:15 to 5:30 p.m. spawned an incredible variety of ocular systems. Some are merely curiosities, while oth- 4:15 p.m. Staff Training for Efficiency ers offer the finest visual potential packed into a small space, limited only by the laws Spotlight on Practice Efficiency: Preparing Event Code 462, $35, Monday, 4:30 to of diffraction or physiological optics. We should be so lucky. (Event Code 338; tickets OPHTHALMIC IMAGES CD, VERSION 2.0 for the Boomers 5:30 p.m. cost $35 each.) Event Code Sp01, no ticket required, Retina-Specific Patient Flow A Natural Festival of Light and Color takes place on Tuesday from 11:30 a.m. to 12:30 Sunday, 3:45 to 5 p.m., in Room #A411. Event Code 538, $70, Tuesday, 9 to 10 a.m. p.m. The subtle splendor of the green flash, the thrill of the rainbow, Alexander’s phe- Efficient Ambulatory Surgery Center Designing Medical Office Space: How to nomenon, the lunar corona, the Specter of the Brocken, the fog bow and the surreal Management Practices Create Efficient, Effective, and Patient- fata morgana are examples of refraction, diffraction and reflection. These and other Event Code 341, $35, Monday, 9 to 10 a.m. Friendly Office Space natural events will be revealed, explained and admired (Event Code 587; $35). Event Code 575, $70, Tuesday, 10:15 Dr. Schwab is a professor and director of cornea and external disease at the Univer- Using Benchmarks to Improve Your Practice a.m. to 12:30 p.m. sity of California, Davis. He is the proud recipient of the 2006 Ig Noble award in Event Code Spe26, no ticket required, ornithology and his forthcoming book, Evolution’s Witness, will be published by Oxford University Press in February 2010. For more practice management sessions, see your Pocket Guide or Final Program. 18 f r i d a y G s a t u r d a y e d i t i o n
  • HONORARY LECTURES MAKE TIME FOR THESE PRESENTATIONS Five Leaders Discuss History, Today’s Issues by lori baker schena, contributing writer N amed for highly respected figures in cal Scholar and attending surgeon at the gases for the treatment of complicated becoming a “lost art,” advances are being ophthalmology, most honorary lec- New York–Presbyterian Hospital Weill detachments. He authored the classic 1971 made in the vitrectomy technique to attach tures take place during a Sympo- Cornell Medical Center in New York City. paper “Finding the Retinal Hole,” which the retina. Research continues into the sium and they often serve as the corner- In addition to introducing cryopexy for still retains relevance. development of smaller and finer instru- stone for the session. If you can’t attend retinal detachment, he pioneered the use RESEARCH OPPORTUNITIES. Dr. Lincoff mentation. The ultimate research oppor- the entire Symposium, consider making of the straight chain perfluorocarbon said that while scleral buckling may be tunity is retina transplantation, where the time in your schedule to hear the hon- orary lecturer’s presentation. The newest honorary lecture at the Academy is the Charles L. Schepens MD Lecture, which takes place today (Friday) during the Retina Subspecialty Day meet- ing. The other lectures below will be pre- sented on Sunday and are all free; no ticket is required. CHARLES L. SCHEPENS MD LECTURE Harvey A. Lincoff, MD, will present The Evolution of Retinal Surgery: A Personal Story (9:54 to 10:14 a.m.) on Friday during Retina Subspecialty Day. This combined meeting with the American Society of Reti- na Specialists, Macula Society, Retina Soci- ety and Club Jules Gonin takes place on Friday and Saturday in Hall A-3 Session Room. ABOUT THE LECTURE. Harvey A. Lincoff, MD, has a passion for the retina that has not been diminished by age or time. To Dr. Lincoff, it feels like yesterday when he traveled as a senior resident in 1954 from Bellevue Hospital in New York City to the Massachu- setts Eye and Ear Infirmary to meet Charles L. Schepens, and saw firsthand the wonders of the hands-free indirect binocular ophthal- See retina history moscope that Dr. through Dr. Lincoff’s Schepens had eyes. designed. With it Dr. Schepens would make a meticulous draw- ing of the detached retina and the retinal break preoperatively. With the drawing on display in the operating room, he found and sealed the break and reattached the retina with remarkable frequency. “When I returned to New York,” Dr. Lincoff said, “I began with the Schepens scope to attach retinas and have been doing so ever since.” While Dr. Lincoff had the greatest admi- ration for Dr. Schepens, they were not without their differences. “When I intro- duced cryopexy for retinal detachment, Dr. Schepens stood by the hot diathermy needle approach; we would debate the two techniques at society meetings. Our peers would introduce us as Drs. Hot and Cold.” During his lecture, Dr. Lincoff will share similar stories and give the audience a rare personal glimpse at the dynamic history of Dr. Schepens and retinal surgery. ABOUT THE SPEAKER. Dr. Lincoff is pro- fessor of ophthalmology, Newhouse Clini- e y e n e t ’ s a c a d e m y n e w s 19
  • HONORARY LECTURES peripheral retina would be transplanted treatment approaches for AMD.” into the central retinal region and func- CHALLENGES AHEAD. In terms of research, tion there. —L.B.S. it is a challenge to get continued funding Some history about Dr. Schepens and for clinical trials from government and how his eponymous lecture came about industry.“The costs, along with the bureau- can be found at the end of the honorary cratic burden, including IRB and privacy lecture previews on page 22. protocols, are creating more and more of a challenge to good clinical research,” Dr. JACKSON MEMORIAL LECTURE Ferris said. —L.B.S. Frederick L. Ferris III, MD, will present Clinical Trials: More Than an Assessment BARRAQUER LECTURE of Treatment Effect (9:32 to 9:57 a.m.) Roger F. Steinert, MD, will present Corneal during the Sunday Opening Session (8:30 Surgery Is Refractive Surgery (11:50 a.m. to 10 a.m.), which takes place in Hall A-3 to 12:10 p.m.) during the Sunday Sympo- Session Room. sium titled 25th Anniversary of the ABOUT THE LECTURE. No one can dispute Excimer Laser (10:45 a.m. to 12:15 p.m.). that clinical trials are expensive to run. This combined meeting with the Interna- Yet the value of this research extends way tional Society of Refractive Surgery of the beyond the treatment effects, noted Fred- American Academy of Ophthalmology erick L. Ferris III, MD. “We gather vital and the European Society of Cataract and data beyond the scope of the original trial, Refractive Surgeons takes place in Hall A-3 and the worth of these data cannot be Session Room. underestimated.” ABOUT THE LECTURE. Roger F. Steinert, In his lecture, Dr. MD, observes that ophthalmology has Ferris will give a his- made great strides in improving optical torical perspective performance through refractive surgery, of clinical trials and and more recently, cataract surgery. the National Eye “Indeed,” he said, “cataract surgery is not Institute, and he will just an anatomical procedure but also a provide several refractive procedure in which we recog- examples of the nize and meet a patient’s vision needs— value of clinical tri- whether that involves making limbal als over time. “For relaxing incisions or implanting a pres- Dr. Ferris offers in- example, I think byopia-correcting IOL.” sight into the value people forget how According to Dr. Steinert, the time of clinical trials. much ridicule was has come to take a similar approach to hurled early on at the idea of scatter pho- corneal transplantation surgery. “We have tocoagulation for diabetic retinopathy,” made great strides in replacing cloudy Dr. Ferris said. “Scatter photocoagulation corneas with clear corneas,” he said. “Yet made about as much sense then as did the our ability to achieve optically excellent pattern bombing in North Vietnam.” Yet corneas comparable to natural corneas findings from the Diabetic Retinopathy has lagged seriously behind this anatomic Study Research Group dramatically iden- success.” tified high-risk proliferative diabetic His lecture will retinopathy and definitively demonstrat- focus on recognizing ed that the benefits of photocoagulation that corneal surgery outweighed the risks. is refractive surgery. Dr. Ferris cited other studies, including While half the job is those from the Diabetes Control and Com- achieving an anatom- plications Trial Research Group, which ically clear cornea, focused on blood glucose control, and the profession now from the Retinopathy of Prematurity must focus on the Research Group, which dramatically other half—giving The bar must be expanded ophthalmology’s understanding patients the optimal raised for corneal of the risk factors for ROP that currently optical performance, surgery outcomes, are in daily use in our neonatal nurseries. he said. This includes says Dr. Steinert. ABOUT THE SPEAKER. Dr. Ferris is NEI borrowing the tools clinical director and director of the Division of refractive surgery such as LASIK and of Epidemiology and Clinical Research PRK once the corneal transplant has there. He joined the NEI in 1973. He was healed, and using the femtosecond laser to chairman of the Age-Related Eye Disease obtain better healing and optical contour. Study starting in 1992 and cochairman of ABOUT THE SPEAKER. Dr. Steinert is pro- the Early Treatment Diabetic Study, which fessor and vice chairman of clinical oph- began in 1980. thalmology at the University of California, RESEARCH OPPORTUNITIES. “The most Irvine. He has authored or coauthored challenging and interesting new research four textbooks, including the definitive opportunity is the development of more text, Cataract Surgery, now in its second effective approaches to slowing or stopping edition, and he has published more than the progression of age-related macular 120 peer-reviewed journal articles and 60 degeneration before it reaches the neovas- book chapters. cular stage,” said Dr. Ferris, and he added, Dr. Steinert served on the Harvard “Accumulating evidence points to new University Medical School faculty from immunologic pathways and possible new 1981 until he was recruited to the Univer- 20 f r i d a y G s a t u r d a y e d i t i o n
  • HONORARY LECTURES sity of California, Irvine in 2004. are rigorous enough. look for disinfecting solutions that are less our current system. Issues that affect the RESEARCH OPPORTUNITIES. There are two ABOUT THE SPEAKER. Dr. Stern has been toxic and more effective, and to improve physician’s ability to practice effectively hot areas in research, and they intersect. in private medical practice since 1997 at contact lens materials that will inhibit need to be considered, not just getting These are the development of the ultimate the Three Rivers Eye Care Center in Mis- attachment of bacteria to the lenses,” Dr. people care and paying for it. That is a endothelium transplant, and the develop- soula, Mont. Stern said. challenge, and it will be for a long time.” ment of femtosecond laser incision tech- Prior to moving to Montana, Dr. Stern CHALLENGES AHEAD. “The politicians —L.B.S. niques to create better incisions and mini- was a professor of ophthalmology for pushing universal health care are focused mize distortion, Dr. Steinert said. almost two decades at the University of on getting people insured to provide access RUEDEMANN LECTURE CHALLENGES AHEAD. “Throughout all of Florida in Gainesville. In 2004, he received to care. Quality of care is a distant second,” Kevin V. Kelley, BCO, FASO, will present medicine, we have an aging population the Honor Award from the Contact Lens he said. “Not a lot of consideration is being The ASO, 1957–2007: Fifty Years of that is living longer, so these people are Association of Ophthalmologists. given to what is happening to the doctors Advancements (3:08 to 3:28 p.m.) during experiencing more degenerative disease. RESEARCH OPPORTUNITIES. “We need to and hospitals. Physicians are just pawns in the Sunday Symposium titled Put the Yet they have high expectations of retain- ing bodily function and not quietly slip- ping into infirmity,” Dr. Steinert said. “This ongoing disconnect between demand and expectation will place enor- mous economic pressure on the system. So far, the general public does not have any sense of that conflict nor any percep- tion that this is an unavoidable issue.” —L.B.S. WHITNEY G. SAMPSON LECTURE George A. Stern, MD, will present Corneal Infections in Contact Lens Wearers: What Have We Learned? (3 to 3:25 p.m.) during the Sunday Symposium titled Ectatic Dis- eases of the Cornea: Treatment With Con- tact Lenses or Surgery (2 to 3:30 p.m.). This combined meeting with the Contact Lens Association of Ophthalmologists takes place in Room A411. ABOUT THE LECTURE. As long as there have been soft contact lenses, there have been corneal infec- tions. “Theories have evolved over time about why these infections occur,” said George A. Stern, MD. “Three years ago— just when we thought we knew everything—a Contact lens disin- worldwide fungus fection must take infection epidemic priority over con- occurred that had sumer conve- never been seen nience, says Dr. before, along with a Stern. surge of amoebic infections that had died out but returned. Both were related to contact lens disinfec- tion and disinfecting solutions.” In his lecture, Dr. Stern will discuss the history of infections in contact lens wear- ers, the reasons for the resurgences, and what the scientific community has learned from the latest round of infections. “We now know that contact lens disinfection must be taken more seriously,” Dr. Stern said. “Patients often don’t think about what is best for their eyes; they only want convenience. And the companies feed into this attitude, making disinfection as sim- ple as possible. But we must make disin- fection more of a priority, focusing on what is most important for the patients’ eyes, not the patients’ convenience.” Dr. Stern also will review FDA proto- cols on disinfecting solutions, and he will discuss whether the rules and guidelines e y e n e t ’ s a c a d e m y n e w s 21
  • HONORARY LECTURES Patient First! Ethics for the Ocularist and that formalized the education of ocular- RESEARCH OPPORTUNITIES. “The devel- a simple, realistic and workable dilating the Ophthalmologist (2 to 3:30 p.m.). This ists and set the requirements necessary opment of porous motility implants that pupil.” combined meeting with the American Soci- to receive a diploma from the ASO, and can be ‘pegged’ in order to impart more CHALLENGES AHEAD. While the ASO has ety of Ocularists takes place in the Thomas in 1980 the establishment of a separate movement to the prosthesis has revolu- 50 years under its belt, it continues to B. Murphy Ballroom 4. National Examining Board of Ocularists tionized artificial eyes,” Mr. Kelley said. experience some growing pains as a pro- ABOUT THE LECTURE. For 50 years, the (NEBO) that produced and administered “The field continues to search for simpler fessional organization. “We want to con- American Society of Ocularists (ASO) has the first certification exam for ocularists. and improved pegging systems that allow tinue expanding membership in the ASO been dedicated to a In his lecture, Mr. Kelley will discuss for even better movement. Newer and bet- within our strict guidelines,” Mr. Kelley threefold purpose: these milestones, including the ASO’s col- ter prosthesis materials are always an area said. “Maintaining that professional quali- to improve and pro- laboration with the Academy, as well as of research, and ocularists will continue ty is one of our challenges as the largest mote research in the future challenges for the profession. to search for a method to incorporate a teaching organization for ocularists in the development of ABOUT THE SPEAKER. Mr. Kelley joined missing aspect into an ocular prosthesis: world.” —L.B.S. ophthalmic pros- the ASO in 1978 when he began his thetics, to advance apprenticeship training under his father, the methods, tech- John J. Kelley Sr. NEW LECTURE HONORS RETINA PIONEER niques and skills of The younger Mr. Kelley, who was its ocularist mem- NEBO certified in 1983, and awarded Never stop dreaming. What seemed impossible yesterday can become a reality tomorrow. bership, and to pro- fellow designation by the ASO in 1986, —Charles L. Schepens, MD Take a look at the past and future of vide the public with has served in a number of high posts with T hose words were the motto of Charles the ASO with Mr. continual improve- the ASO, including chairman of the Edu- L. Schepens, MD, a brilliant scien- Kelley. ments in the field. cation Committee for more than 10 years. tist, compassionate retina surgeon According to Kevin Mr. Kelley has also served as chairman of and pioneer in the field of retinal eye V. Kelley, BCO, FASO, this mission has the Written Exam Committee for the care. As well as inspiring others—he served as the foundation for the advances NEBO, and as an examiner for the NEBO trained 223 fellows who went on to in ocular prosthetics—helping both to practical exam. become leading academicians and clini- standardize training and to provide cus- In 1992, Mr. Kelley received two U.S. cians—Dr. Schepens’ own life is a testa- tom artificial eyes of the highest quality. patents and a Canadian patent for the ment to the power of single-minded dedi- “We have experienced a number of invention of the SLP self-lubricating cation to science, as well as courageous milestones in the past 50 years,” Mr. Kelley prosthesis, which addresses the problem action in the face of insurmountable odds. said. These include the creation of a train- of inadequate lubrication on the surface The Academy hosts the inaugural ing program by the ASO in 1973 and 1974 of the prosthesis. Charles L. Schepens MD Lecture at Reti- na Subspecialty Day. A project of the Schepens International Society and the Retina Research Foundation of Houston, the lecture is intended to honor Dr. Schepens, recognize the outstanding work DR. SCHEPENS. This morning (Friday) dur- of retina scientists, and provide a step ing Retina Subspecialty Day, the Academy forward toward the goal of eradicating honors the memory of Dr. Schepens with blindness caused by vitreoretinal diseases, its inaugural honorary lecture in his name. according to Alice McPherson, MD, a life- long friend of Dr. Schepens who worked people over the Pyrenees from France into to make the lectureship a reality. Spain during World War II—all the while Dr. McPherson, president of the Retina masquerading as a Nazi collaborator. Research Foundation and professor of A native of Belgium, Dr. Schepens ophthalmology at Baylor College of Medi- became a part of the underground after cine, noted that Dr. Schepens’ all-absorb- the Nazis invaded. After being arrested ing commitment to science benefited both twice, he fled to France and bought a clinicians and patients worldwide. dilapidated lumber mill in the town of Dr. McPherson studied as a fellow Mendive, France, using its tramway to under Dr. Schepens at the Massachusetts smuggle people and documents over the Eye and Ear Infirmary and, in fact, was border. the first woman he ever trained. “If it He eventually settled in the United were not for his support, I wouldn’t have States in 1947 and became the first direc- a career today,” she said. tor of the retina service at the Massachu- Known as the “Father of Modern Reti- setts Eye and Ear Infirmary. na Surgery,” Dr. Schepens invented the In 1950, Dr. Schepens founded the hands-free binocular indirect ophthalmo- Retina Foundation. In 1967, he founded scope, cobbling it together from bits and the Retina Society, which remains to this MUSEUM OF VISION, AMERICAN ACADEMY OF OPHTHALMOLOGY pieces he found while living in London day a forum for leaders in the field of reti- during the aftermath of World War II. He na. Then in 1974, his Retina Foundation also performed the first scleral buckling was renamed the Schepens Eye Research procedure in the United States, intro- Institute (SERI), which has published duced the encircling scleral buckle and more than 4,000 papers, trained over 600 developed the laser Doppler flowmeter vision scientists and receives more fund- and the scanning laser ophthalmoscope, ing for eye research than any other eye as well as writing more than 350 publica- organization in the United States. He also tions, ranging from scientific studies to founded the Schepens International Soci- books. ety, which offers leadership opportunities A few days before Dr. Schepens died in and an award to individuals who have March 2006, the consul general of France made contributions to ophthalmology. presented him with the French Legion of —Barbara Boughton, Honor award for smuggling more than 100 Contributing Writer 22 f r i d a y G s a t u r d a y e d i t i o n