Saturday, November 11, 2017

Snippets from Saturday at AAO

Packed day. I have never seen so many ophthalmologists in one place. I used to go to the ASCRS meetings, and sometimes ARVO... but this is... bigger.

Some highlights:

Exhibit hall... 

At the big ophthalmology meetings these are dominated by top dollar technologies, so not a huge lot there of interest to our dry eye world, but here are notes from a few of my visits:

  • Lipiflow presentation (in the Johnson & Johnson family now). 
    • Audience question: "Does it still work when most glands are truncated?" Answer: "Yes.... It's mostly about preserving glands that are functional - that's the way to present it to patients."
    • One presenter said she has always done a thorough cleansing with Ocusoft on a sponge immediately before Lipiflow, and patients seemed to do better that way, but is now considering switching to Blephex. 
    • Audience question: "If the patient is needing both Lipiflow and cataract surgery, how far in advance of surgery should Lipiflow be done?" Answer: "Give it plenty of time. Usually you see a huge difference in the topography in a month."
  • Allergan: Among the enormous team they had there I hunted down someone who could talk to me about Refresh PM. He was confident it is coming back quite soon - had heard two weeks ago that it would be about a month.
  • Alcon: I was NOT able to hunt down anyone who knew anything about when Bion Tears will be back. ("Is that an Alcon product? Really?") I have since learned that this has yet again been rebranded as Genteal Tears (pf version) so apparently Alcon's site, not to mention staff, just haven't quite caught up with this.
  • Ocusoft: Had a gander at their latest stuff which I'd been meaning to catch up with. Basically knockoffs of Avenova (Hypochlor) and Refresh Optive (Retaine Tears). Going to add these to the DryEyeShop.
  • Nanotears (Altaire). Breezed by and looked at ingredients - looks like basically a Systane family knockoff. I have my own history with Altaire so I didn't stay to chat. 
  • Rendia - patient education videos, etc. Had a good chat with these folks, will consider whether getting access to their videos for DEZ would be a good idea, also considering what it would look like to collaborate with an outfit like this on making educational videos on more topics of interest to the severe dry eye and the scleral lens crowds.

Meeting with Shire...

In September 2016 I met someone who worked in patient advocacy at Shire, at the TFOS conference in Montpellier. We connected later in the year about some projects to explore, but we eventually lost touch and he has moved on from that group. So today I met with someone new to that group who is a true veteran of the patient-advocacy-within-the-pharmaceutical world, and it was a pleasure. This is not someone from the marketing side trying to play nice with patients. This is someone whose professional focus is all about increasing patient access to treatment, via all sorts of channels including education about insurance, and about legislative activism and so on. Anyway, enjoyed the meeting, kicked around some possibilities and will keep in touch.

Cornea Subspecialty Day...

I did not bother with the three morning sessions, which weren't in core areas of interest for me (corneal infections, keratoplasty, and conjunctival tumors). But the afternoon held a lot more of interest.

Section IV - Anterior Segment Imaging

Attended this more out of personal interest than anything related to dry eye - dates back rather to my early advocacy days for LASIK complications folks. 

Dr Majmudar on aberrometry... I love people who take aberrometry seriously. (And I can't help loving the term "abberropia" which so aptly describes post LASIK vision for some of us.) Fun to hear about great ways they're using it for more informed diagnosis and surgical planning in non elective procedures.

Dr Shousha (Bascom Palmer, another of my favorite places) and later Frank Price on intraoperative OCT - a real time cross section of the cornea... loved it.... helping prevent descemets perforation during keratoplasty or more accurately diagnose complications post operatively.

Section V: Keratoconus

Learned lots about diagnosis, and especially early diagnosis of Keratoconus... wasn't really a huge area of interest until the last couple of years and the "Great Saline Crisis" when I suddenly made the acquaintance of vast hordes of keratoconics and got curious about how it works. Dr Michael Belin was really adamant about the importance of diagnosing subclinical keratoconus and treating early to avoid vision loss. Dr Debbie Jacobs, one of my favorite people (medical direction at BostonSight) presented on the full range of specialty contact lenses from piggybacking to PROSE. There was a presentation on corneal crosslinking by a colleage of Dr Glassner's who wasn't able to make it.

The most remarkable thing to me from this entire section was that everyone gets very excited about  surgery, and almost no one considers contacts/sclerals/PROSE. Dr Jacobs presentation was excellent and yet felt like a blip in an ocean of cutters. Hmmmm. I probably wouldn't be raising the point if it weren't that so many scleral lens and PROSE users that I know have had corneal grafts or other very invasive surgeries - and still needed the lenses afterwards - which makes one wonder if (in situations where it might have been appropriate) they were offered that option before surgery.

Section VI: Inflammatory Conditions of the Anterior Segment

This was the only cornea session really touching much on our pet topics here related to dry eye. 

Dr Anat Galor (Bascom Palmer) presented on the many dry eye diagnostic tests available now (differentiating between those that spit out numbers and those that are qualitative only). She also mentioned a Sjogrens-specific test available from B&L, but the patient cost was quite high ($614).

I'm looking up my notes on the allergic conjunctivitis presentation and reflecting on the fact that I have been sneezing nonstop today, despite the report being low for New Orleans today. But I REALLY enjoyed this presentation by Dr Deepinder Dhaliwal (UPMC). Technical information but a lot of common sense practical stuff that people ignore - like, don't rub your friggin' eyes! and that if itching is present, allergy is very likely. And to wash all your bedding in hot water. Wash your hands and change your clothes when you get home, when the pollen count's high. Went over treatment regimens, all the usual stuff but she also mentioned a sublingual immunotherapy which is apparently effective for ocular allergy? I must look this one up. 

Dr Wuqaas Munir on Stevens Johnson Syndrome - I really appreciated getting a better understanding of how this disease works and what happens when it's chronic. Only surprised to not hear more about PROSE as a treatment. 

Dr Steve Pflugfelder (Baylor; world known dry eye specialist incidentally) - breath of fresh air to hear PROSE mentioned casually in every context where it OUGHT to come up, as though he assumes everyone is already up to speed on that. Anyway his talk was on Sjogrens. One of the things that clicked with me was the intense environmental vulnerability of the Sjogrens eyes. He mentioned a study - it went by too fast and I haven't found it yet - where just 90 minutes' exposure to a bad environment for eyes (eg very low humidity) was enough to cause measurable clinical change. - Later on during Q&A I was interested to hear him sum up hormone based treatments as all very interesting but... little evidence of actual efficacy. Oh and one last highlight, someone asked about preservative free steroids, and again, he managed to make it sound like this should be NORMAL (thank you Dr P). 

Last, there was a great little presentation by Dr Chris Rapuano (Wills Eye), wish he hadn't disappeared so quickly afterwards so I could have thanked him, on SLK, which he described as constantly getting missed in diagnosis. "Lift the lid and make them look down!". Often occurs alongside dry eye and/or bleph. More common among middle ged females. Associated with thyroid disease. Lots of superior staining and a 'velvety' pattern.

After that it was all about waiting for uber and finding really good gumbo. Tomorrow is another day!

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