Is a future without glasses or contacts possible?

July 12, 2018

James P. McCulley, M.D.

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Tired of wearing glasses or contacts? Vision-correction surgery might be a good option for you.

Does this scenario sound familiar? When you’re wearing glasses or contacts, your vision is crystal clear: You can drive, watch a movie, or read without problems. When you don’t have them, however, you struggle to see and have to ask someone else to read the fine print for you.

According to data from The Vision Council, more than 76 percent of people in the U.S. use some sort of vision correction. That means there’s a lot of patients wearing glasses or contacts, not to mention carrying prescription sunglasses or “cheaters” for reading, which can be a hassle. Even if the extra gear doesn’t bother you, having less-than-perfect vision can be dangerous in everyday situations, such as watching your children at the pool, or during emergencies, such as a fire or car accident.

If you can’t tolerate contact lenses – or don’t like them or don’t like wearing glasses – vision surgery might be a good option for you. Patients can undergo effective, low-risk procedures to correct nearsightedness, farsightedness, astigmatism, and other visions problems. Today, advanced eye procedures can significantly reduce the need for corrective eyewear, and new technology emerges every year. In fact, a future without glasses or contact lenses might not be farfetched!

History of vision surgery

Over the past 40 years, vision surgery has come a long way. Radial keratotomy (RK), was the first attempt at refractive eye surgery for those with nearsightedness. It was introduced in the 1970s but is no longer in use today – for good reason.

When RK was developed, the surgical equipment was approved by the U.S. Food and Drug Administration (FDA) but the procedure itself was not. To determine whether RK was effective and safe, researchers designed the Prospective Evaluation of Radial Keratotomy (PERK) clinical trial. Researchers found that RK was unpredictable – patients often suffered with fluctuating vision and glare at night, and there were other significant side effects of the procedure. The trial also found that study participants were at increased risk to prematurely need bifocals.

In the 1990s, the excimer laser procedure was approved by the FDA, and another type of tool for refractive eye surgery, photo refractive keratectomy (PRK), was introduced. The laser sculpts the cornea – the clear dome that covers the iris and the pupil – to correct refractive errors, including nearsightedness, farsightedness, and astigmatism. Although effective, this type of laser eye surgery had a slow recovery time, significant side effects, and a considerable amount of pain until the eyes healed, usually a week or more.

Total Eye Health

Each year, our ophthalmologists treat thousands of patients with a wide variety of eye conditions. This high volume provides us with extensive experience that translates to the best possible care for our patients. Ophthalmologists share the expertise of the team and the importance of one-stop, comprehensive eye care at UT Southwestern.

Laser eye surgery today

LASIK

In 1999, the next generation in laser eye surgery, LASIK (laser-assisted in situ keratomileusis), became available for those with nearsightedness, farsightedness, and astigmatism. To perform LASIK, surgeons create a flap in the cornea, use a laser on the underlying exposed tissue to sculpt the cornea, and then replace the flap to correct vision problems. LASIK transformed eye surgery because it minimized pain after the procedure and shortened recovery time from a week to just a few hours or days. Learn more about LASIK at UT Southwestern.

Intraocular lens (IOL)

The eye has a crystalline lens, which is a transparent structure that works with the cornea to refract light and focus it on the retina. A supplemental intraocular lens (IOL) can be inserted to correct refractive errors without taking out the natural crystalline lens, though this procedure is not common. It can be effective for patients with extreme near- or farsightedness.

A refractive lens exchange (also known as lens replacement surgery or clear lens extraction) is another option. This procedure replaces the crystalline lens with an intraocular lens to correct nearsightedness or farsightedness. This also can be effective for patients with extreme refractive errors.

Monofocal and multifocal lenses

There also are options for those with cataracts, a clouding of the lens in the eye that affects vision. By age 80, the majority of people have a cataract or have had surgery to correct one. During our younger years, the crystalline lens is flexible and allows light to be focused from all distances so we can see at all distances, but as we get older it loses its elasticity, making it harder to focus. The lens also starts to become cloudy, i.e. develop cataracts, which scatters light, making us light sensitive, and have blurry vision.

Early on, most people use bifocals or trifocals to correct these problems, but as the loss of elasticity continues and vision deteriorates, surgical options become attractive, especially once vision blurring also sets in. For someone who has a cataract (with or without astigmatism), we can surgically remove the cataract and use an intraocular lens to correct refractive errors for distance. This typically is covered by insurance (no astigmatism correction) or partially covered (with astigmatism correction).

These lenses can correct astigmatism and vision for distance, for example, but patients likely would still need eyeglasses or contact lenses for intermediate vision (to see a computer) and near vision (to read a book). There also is a procedure in which a lens for distance is implanted in one eye and a lens for near vision is implanted in the other. This is called monovision. Although these can be effective, they lack depth perception and not all patients can tolerate them.

Multifocal lenses can correct vision for all three targets (distance, intermediate, and near), as well as astigmatism. Depending on the power of the intermediate/near lens, wearing glasses might still be necessary but only some of the time.

The future of vision surgery

In the U.S., trifocal interocular lenses are currently in FDA trial. Also in clinical testing are monofocal lenses, which can be shaped with a laser after implantation to tweak the power of the lens. In other countries, there are interocular lenses that can focus. In the U.S, the Crystalens, which is supposed to have focus capability, is available. However, we rarely use them at UT Southwestern because results are highly variable. 

“Today, advanced eye procedures can significantly reduce the need for corrective eyewear, and new technology emerges every year. In fact, a future without glasses or contact lenses might not be farfetched!”

– James P. McCulley, M.D.

What patients should know before having eye surgery

When considering any type of surgery, carefully weigh the benefits and risks. Though most of these procedures are safe and low-risk, some people find they experience light sensitivity after surgery, which is something to consider. In rare cases, vision surgery can lead to infection, vision loss, or blindness.Successful eye surgery is dependent on several factors, such as a patient’s eye health, the type of procedure selected, and the presence of other medical conditions that could complicate the surgery or make the results less predictable. Patients who have problems with healing, who are at high risk for a heart attack, or who have chronic conditions such as rheumatoid arthritis or a heart arrhythmia might not be eligible for certain procedures.

Additionally, patients with Type 2 diabetes tend to have a fragile eye surface that can complicate healing, so vision surgery should be carefully considered. If you have dry eye syndrome – which affects 3.2 million women and 1.68 million men over age 50 – the condition can worsen after eye surgery. Ask your doctor to help you get your symptoms under control and take precautionary measures before eye surgery.

Where you have a procedure also matters. Many standalone eye centers offer cataract surgery and LASIK, but these clinics likely lack expertise in whole-eye-patient care. At the UT Southwestern James W. Aston Ambulatory Care Center and Monty and Tex Moncrief Medical Center at Fort Worth, patients can get the care they need for preexisting conditions that might affect their surgical outcomes, and they also can benefit from the expertise of surgeons who specialize in particular procedures.

New and emerging corrective vision surgeries are exciting and, in the future, could potentially make the need for glasses and contact lenses obsolete. Today, the majority of these surgeries are elective procedures. Vision-correction surgery can be life-changing, but it’s not for everyone.

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Use of intraocular lenses relatively safe for treatment of cataracts in infants ages 7 to 24 months old

Sept. 14, 2019

Primary insertion of an intraocular lens during pediatric cataract surgery is the standard of care for children age 2 years and older. Although intraocular lens implantation has become more common in patients younger than 2 years, concerns about adverse events, re-operations and refractive changes continue to be serious considerations in infants.

To evaluate these concerns, Erick D. Bothun, M.D., and a research team with Ophthalmology at Mayo Clinic in Rochester, Minnesota, conducted a retrospective review of infants ages 7 to 24 months treated by surgeons at 10 Infant Aphakia Treatment Study (IATS) sites during that study’s enrollment period.

“The IATS assessed the outcomes and complications of unilateral cataract surgery in infants ages 1 to 7 months,” says Dr. Bothun. “This study, the Toddler Aphakia and Pseudophakia Study (TAPS), is a retrospective consecutive case series of cataract surgery procedures performed in infants ages 7 to 24 months by surgeons who simultaneously were enrolling younger babies in the IATS.

“Because the surgical and clinical care of the TAPS mirrored that of the IATS, the outcomes of surgery for children ages 7 to 24 months in the TAPS can be compared with those reported for children ages 1 to 7 months in IATS.”

The IATS five-year results from the Infant Aphakia Treatment Study Group appeared in JAMA Ophthalmology in 2014. The first TAPS cohort results were published in Ophthalmology in 2019.

Infants were eligible for inclusion in the TAPS registry if they had undergone unilateral or bilateral cataract surgery performed by an IATS surgeon prior to age 24 months during the IATS enrollment period (Jan. 1, 2004, through Dec. 31, 2010). This first manuscript from the TAPS registry involved only the infants with unilateral cataract, and for this effort, the TAPS exclusion criteria largely paralleled the IATS criteria.

The 10 IATS sites registered 96 infants ages 7 to 24 months with a history of unilateral cataract surgery between 2004 and 2010. Ultimately, 56 infants were included in the unilateral TAPS.

Surgery was performed on the right eye in 31 infants (55%) and on the left eye in 25 infants (45%). A primary intraocular lens was inserted in 51 infants (91%). Intraocular lenses were implanted in 20 of 24 infants (83%) who were 7 to 12 months of age, and in 31 of 32 infants (97%) who were 13 to 24 months of age.

Clinical and surgical records were reviewed for visual acuity, refractive correction, patching compliance, intraocular pressure, ocular motility, and anterior segment and ocular fundus examination findings until the final study visit, when the infants were between 4 and 6 years of age. Other patient details included gender, age at surgery, cataract description, strabismus measurements and intraocular lens power.

Main outcome measures

Intraoperative complications and adverse events were recorded using the IATS criteria. Intraoperative complications occurred in four infants (7%). An additional unplanned intraocular surgery occurred in 14% of infants. Adverse events were identified in 24%, with a 4% incidence of glaucoma suspect. Strabismus surgery was performed in 40% of the infants with strabismus before 4 years of age.

Visual acuity, strabismus, stereopsis and glaucoma outcomes were not statistically different between the study groups. Neither adverse events nor intraocular re-operations were more common for infants with surgery at 7 to 12 months of age than for those who underwent surgery at 13 to 24 months of age.

“Although most infants in TAPS between 7 months and 2 years of age underwent intraocular lens implantation concurrent with unilateral cataract removal, the incidences of complications, re-operations and glaucoma appear much lower than when intraocular lenses were used by the same surgeons in infants younger than 7 months of age in the IATS,” says Dr. Bothun. For infants who received an intraocular lens in IATS, intraoperative complications occurred in 28%, adverse events in 81%, and additional intraocular surgeries in 72%.

“Due to inflammatory risks, structural challenges and characteristics of eye growth, the IATS and other efforts showed that cataract surgery risks increase in infancy compared with older children and teenage youth. Prior to the TAPS, the literature has lacked documentation regarding cataract surgery outcomes in infants just older than the IATS group. The TAPS findings support the relatively safe use of intraocular lenses in infants between 7 and 24 months of age,” says Dr. Bothun.

For more information

The Infant Aphakia Treatment Study Group. Comparison of contact lens and intraocular lens correction of monocular aphakia during infancy: A randomized clinical trial of HOTV optotype acuity at age 4.5 years and clinical findings at age 5 years. JAMA Ophthalmology. 2014;132:676.

Bothun ED, et al. Outcomes of unilateral cataracts in infants and toddlers 7 to 24 months of age: Toddler Aphakia and Pseudophakia Study (TAPS). Ophthalmology. 2019;126:1189.

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Nation’s Leading Medical Specialty Organizations Applaud Congressional Leaders’ Introduction of Legislation to Improve Oversight and Transparency in Prior Authorization

WASHINGTON, June 5, 2019 — A coalition of eight national medical specialties today pledged support for the bipartisan Improving Seniors’ Timely Access to Care Act of 2019 (H.R. 3107), legislation that would protect patients from unreasonable Medicare Advantage plan requirements that needlessly delay or deny access to medically necessary care. The legislation is sponsored by Reps. Suzan Delbene, D-Wash., Mike Kelly, R-Pa., Roger Marshall, MD, R-Kan., and Ami Bera, MD, D-Calif. 

Currently, Medicare Advantage plans require physicians to obtain advance approval before physicians can provide certain services to their patients. This prior authorization process is intended to control costs by reducing medically unnecessary tests and procedures. Rather than accomplish this goal, many health plans are now widely using prior authorization indiscriminately, creating hurdles and hassles for patients and their physicians that lead to treatment delays that may endanger their health. 

The process for obtaining this approval is lengthy, typically requiring physicians or their staff to spend the equivalent of two or more days each week negotiating with insurance companies. This time would better be spent taking care of patients, especially because the vast majority of these requests are ultimately approved. 

Physicians report devastating results from the worst prior authorization delays, including blindness, loss of function and tumor growth. 

The Improving Seniors’ Timely Access to Care Act is based on a consensus statementon prior authorization adopted by leading national organizations representing physicians, hospitals and health plans. The bill would improve the current prior authorization system by requiring the Centers for Medicare & Medicaid Services (CMS) to regulate Medicare Advantage plans on prior authorization’s use. 

The legislation would also bring greater transparency to the prior authorization process by requiring Medicare Advantage plans to report to CMS on the extent of their use of prior authorization and the rate of approvals or denials by service and/or prescription medication. Over 100 members of Congress called for such reform in a bipartisan letter to CMS last year. 

In conjunction with the bill’s introduction, the Regulatory Relief Coalition, the group of eight medical specialty societies, released results of a physician survey that details the extent to which abusive prior authorization policies are putting patients at risk and increasing burdens on physician practices.  

The survey results include the following:

  • An overwhelming number of physicians (87%) report that prior authorization has a significant (40%) or somewhat negative (47%) impact on patients’ clinical outcomes.
  • A third of physicians (32%) report that their patients often abandon their treatment because of prior authorization.
  • Three-quarters of physicians (74%) report that during the past five years, stable patients have been asked to switch medications by their health plan even though there was no medical reason to do so.
  • Eighty four percent of physicians report that the burden associated with prior authorization has significantly increased over the past five years, with more than half of all practices subjected to 11 or more requests each week, with many finding these requests exceed 40 per week. 

“For more than two years, the Regulatory Relief Coalition made it our responsibility to chip away at barriers that deny our patients timely access to medically necessary care, and the walls enabling prior authorization’s abuse are about to come down,” said George A. Williams, MD, president of the American Academy of Ophthalmology, one of the coalition’s members.   

Echoing his sentiments, Ann R. Stroink, MD, chair of the American Association of Neurological Surgeons and Congress of Neurological Surgeons Washington Committee, concluded, “With the Improving Seniors’ Timely Access to Care Act, a strong, bipartisan group of elected officials in Congress is saying enough is enough, care delayed is care denied, and America’s seniors deserve the care that they expect from the Medicare program.” 

About the Regulatory Relief Coalition

The Regulatory Relief Coalition is a group of eight national physician specialty organizations advocating for a reduction in Medicare program regulatory burdens to protect patients’ timely access to care and allow physicians to spend more time with their patients. 

 American Academy of Neurology ¨ American Academy of Ophthalmology ¨ American Association of Neurological Surgeons ¨ American College of Cardiology ¨ American College of Rheumatology ¨ American College of Surgeons ¨ American Urological Association ¨ Congress of Neurological Surgeons

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Google Research Shows How AI Can Make Ophthalmologists More Effective

Study published in the journal of the American Academy of Ophthalmology shows that together, AI and physicians can improve eye care

A picture of a hand touching a screen of algorithms.

MAR 18, 2019

SAN FRANCISCO  – March 18, 2019 – As artificial intelligence continues to evolve, diagnosing disease faster and potentially with greater accuracy than physicians, some have suggested that technology may soon replace tasks that physicians currently perform. But a new study from the Google AI research group shows that physicians and algorithms working together are more effective than either alone. It’s one of the first studies to examine how AI can improve physicians’ diagnostic accuracy. The new research will be published in the April edition of Ophthalmology, the journal of the American Academy of Ophthalmology.

This study expands on previous work from Google AI showing that its algorithm works roughly as well as human experts in screening patients for a common diabetic eye disease called diabetic retinopathy. For their latest study, the researchers wanted to see if their algorithm could do more than simply diagnose disease. They wanted to create a new computer-assisted system that could “explain” the algorithm’s diagnosis. They found that this system not only improved the ophthalmologists’ diagnostic accuracy, but it also improved algorithm’s accuracy.

More than 29 million Americans have diabetes, and are at risk for diabetic retinopathy, a potentially blinding eye disease. People typically don’t notice changes in their vision in the disease’s early stages. But as it progresses, diabetic retinopathy usually causes vision loss that in many cases cannot be reversed. That’s why it’s so important that people with diabetes have yearly screenings. Unfortunately, the accuracy of screenings can vary significantly. One study found a 49 percent error rate among internists, diabetologists, and medical residents.

Recent advances in AI promise to improve access to diabetic retinopathy screening and to improve its accuracy. But it’s less clear how AI will work in the physician’s office or other clinical settings. Previous attempts to use computer-assisted diagnosis shows that some screeners rely on the machine too much, which leads to repeating the machine’s errors, or under-rely on it and ignore accurate predictions. Researchers at Google AI believe some of these pitfalls may be avoided if the computer can “explain” its predictions.

To test this theory, the researchers developed two types of assistance to help physicians read the algorithm’s predictions.

  • Grades: A set of five scores that represent the strength of evidence for the algorithm’s prediction.
  • Grades + heatmap: Enhance the grading system with a heatmap that measures the contribution of each pixel in the image to the algorithm’s prediction.

Ten ophthalmologists (four general ophthalmologists, one trained outside the US, four retina specialists, and one retina specialist in training) were asked to read each image once under one of three conditions: unassisted, grades only, and grades + heatmap.

Both types of assistance improved physicians’ diagnostic accuracy. It also improved their confidence in the diagnosis. But the degree of improvement depended on the physician’s level of expertise.

Without assistance, general ophthalmologists are significantly less accurate than the algorithm, while retina specialists are not significantly more accurate than the algorithm. With assistance, general ophthalmologists match but do not exceed the model’s accuracy, while retina specialists start to exceed the model’s performance.

“What we found is that AI can do more than simply automate eye screening, it can assist physicians in more accurately diagnosing diabetic retinopathy,” said lead researcher, Rory Sayres, PhD.“AI and physicians working together can be more accurate than either alone.”

Like medical technologies that preceded it, Sayres said that AI is another tool that will make the knowledge, skill, and judgment of physicians even more central to quality care.

“There’s an analogy in driving,” Sayres explained. “There are self-driving vehicles, and there are tools to help drivers, like Android Auto. The first is automation, the second is augmentation. The findings of our study indicate that there may be space for augmentation in classifying medical images like retinal fundus images. When the combination of clinician and assistant outperforms either alone, this provides an argument for up-leveling clinicians with intelligent tools.”

About the American Academy of Ophthalmology

The American Academy of Ophthalmology is the world’s largest association of eye physicians and surgeons. A global community of 32,000 medical doctors, we protect sight and empower lives by setting the standards for ophthalmic education and advocating for our patients and the public. We innovate to advance our profession and to ensure the delivery of the highest-quality eye care. Our EyeSmart® program provides the public with the most trusted information about eye health. For more information, visit aao.org.

About Ophthalmology

Ophthalmology, the official journal of the American Academy of Ophthalmology, publishes original, peer-reviewed, clinically-applicable research. Topics include the results of clinical trials, new diagnostic and surgical techniques, treatment methods, technology assessments, translational science reviews and editorials. For more information, visit www.aaojournal.org.

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Who Does What: 5 Key Roles in the Ophthalmic Practice

Written By: Michael MottAdd to My To-Do ListComments1 Views2170

Every ophthalmic practice runs operations a bit differently, but most involve several key roles. Whether you plan to join a large practice or set up a solo ophthalmology practice, here’s a guide to the most common roles. By knowing who does what, you’ll be able to run a more efficient practice and, ultimately, provide the best patient care.

The scope of each role will vary significantly, depending on the size of the practice. To give you a behind­-the­-scenes look at the ophthalmic practice, YO Info spoke with two seasoned practice administrators about the main positions in their offices and the job duties of each.

1. The conductor —­ your practice administrator/office manager.“Think of this position as the orchestra conductor of the practice,” said Nicole Kesten, whose Chicago Glaucoma Consultants is a three-MD/one-OD private outfit with three locations operating in the greater Chicago area. “Staff play many different parts, and it’s up to the administrator to create office harmony and fill in the gaps as needed.”

Typical duties include:

  • Preparing payroll;
  • Obtaining insurance and benefits for staff;
  • Hiring, training and firing;
  • Paying bills;
  • Negotiating contracts with vendors;
  • Keeping current on the latest government regulations and mandates;
  • Providing productivity reports to physicians;
  • Serving as compliance officer.

At the Virginia Retina Center, Joanne Mansour’s group consists of four ophthalmologists working in three offices — one main and two satellites. In a practice this size, each location might have its own office manager, overseen by a single practice administrator.

“We might also wear more than one hat,” she said. “In smaller practices, for example, office managers might serve as a receptionist, a biller and a scribe at times.”

2. The ambassador —­ your front desk staff. “They are the first­-line ambassadors to the practice,” Kesten said. “Patients might interact with the front desk many times before actually meeting the ophthalmologist.” It’s important for these staff members to have a thorough knowledge of the physician’s background, practice experience and general triage.

The main duties of front desk staff include:

  • Making and confirming appointments over the phone and in person;
  • Checking patients in as they arrive;
  • Arranging for referrals;
  • Triaging patient concerns;
  • Prepping charts;
  • Obtaining authorizations for surgery;
  • Scanning documents into the electronic health record system.

3. The ones who make sure you get paid —­ billers. Simply put, this position collects payments. If your office doesn’t accept insurance and everything is paid at the time of service, this position is very straightforward; however, most offices accept hundreds of different insurance plans. Thus, billers often have more complex duties, which can include:

  • Entering insurance charges for patients;
  • Coding exams;
  • Scrubbing claims to ensure proper payment;
  • Collecting balances;
  • Answering billing questions for patients.

4. The staff who prepare patients ­— ophthalmic technicians. This position casts a wide net. In general, technician duties include:

  • Performing the initial workup on patients as well as diagnostic tests;
  • Assisting physicians with in­-office procedures;
  • Ordering clinical supplies and ensuring physician lanes are stocked;
  • Sterilizing instruments.

Here, too, the size of your business matters. As a high­-volume glaucoma practice with around 22,000 patient encounters a year, Kesten’s Chicago Glaucoma Consultants breaks technicians into three subgroups to maximize an efficient patient flow:

  • Testers administer all diagnostic tests under the direction of the physician and process them via the EHR.
  • Work­-up technicians collect all relevant information required for the patient’s exam.
  • Scribes accompany the doctor during his or her evaluation, document all findings and send exam work to the primary care physician.

“All of our techs work as a cohesive team,” Kesten said. “And in many ways, they are an assembly line, preparing the patient to see the doctor all the way through the evaluation.”

Other Staff. There are also a number of other roles that you might have to fill depending upon your subspecialty and your practice dynamics:

  • Surgery coordinators counsel patients after the physician has recommended surgery and take care of everything associated with the case leading up to the procedure.
  • Opticians assist patients with all optical needs, including glasses and contact lenses, and oftentimes assist with refraction.
  • Photographers are especially common in retina practices and perform diagnostic imaging.
  • IT specialists handle all of the practice’s technology needs, ensuring that servers are up to date and addressing any other computer or EHR issues your staff might encounter, from software updates to ransomware attacks. Smaller practices sometimes outsource IT help.

5. The physician … and organizer —­ you. Most patients can choose from whom they receive care. Even if they love the ophthalmologist, they might go elsewhere if the office is poorly run. As a physician, you’re more than just the doctor. You must also be an effective organizer and facilitator of a large group of staff.

“Most patients come to us because of our doctors’ reputations,” Kesten said. “But I truly believe patients stay with us because of the full package of service that all of the staff provide.”

* * *

About the author: Mike Mott is a former assistant editor for EyeNet Magazine and contributing writer for YO Info.

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Relying on Dr. Google to Diagnose Eye Problems may be Dangerous to Your Health

Relying on the internet to diagnose eye problems may be dangerous to your health. A new study shows a popular online symptom checker was incorrect 74% of the time.

OCT 29, 2018

Study shows popular online symptom checker was incorrect 74 percent of the time, often assesses symptom severity incorrectly

CHICAGO –  Oct. 29, 2018 – A study examining the diagnoses generated by WebMD Symptom Checker showed the online tool was correct only 26 percent of the time. And the recommendation for the top diagnosis was often inappropriate, at times recommending self-care at home instead of going to the emergency room. The research will be presented today at AAO 2018, the 122nd Annual Meeting of the American Academy of Ophthalmology. The researcher suggests ophthalmology-related symptom checkers have an inherent limitation because most eye diseases and conditions require an in-person examination.

Lead researcher Carl Shen, M.D., an ophthalmology resident at McMaster University in Canada, was inspired to conduct the study by his patients, who often come to appointments with an incorrect self-diagnosis or preconceived notions about their condition. He wants to help patients better understand and interpret the eye health information they find online.

To conduct the study, both medical and non-medical personnel input 42 clinical scenarios into the popular WebMD Symptom Checker. Results were then compared with the known diagnosis. The top diagnosis returned was correct in just 26 percent of cases. While the correct diagnosis did appear within the top three results 40 percent of the time, it wasn’t even an option in 43 percent of the cases.

The assessment of symptom severity was also often incorrect. In 14 of 17 cases, the online symptom checker made incorrect recommendations about what the patient should do next, such as self-care at home or getting immediate treatment.

While WebMD can arrive at the correct clinical diagnosis, a significant proportion of common ophthalmic diagnoses are not captured, Dr. Shen concluded.

“Sometimes doing research online can be helpful in identifying possible conditions, and it’s good to be an informed patient,” Dr. Shen said. “But it’s also true that often these online symptom checkers do not arrive at the correct diagnosis. And the wrong recommendation on what to do with that diagnosis could be dangerous. The technology used in these online symptom checkers still have a long way to go in terms of accuracy.”

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Surgeon meets challenges of performing gene therapy

Audina M. Berrocal, MD, of Bascom Palmer Eye Institute, performed the 1-hour surgery in a Florida boy with Leber congenital amaurosis.

Audina Berrocal headshot

Audina Berrocal

On March 22, a Florida boy underwent gene therapy with Luxturna for treatment of inherited retinal disease at the Bascom Palmer Eye Institute, a first for the institution.

“Of course there were challenges,” the boy’s surgeon, Audina M. Berrocal, MD, told Healio.com/OSN.

SEE ALSO

Luxturna (voretigene neparvovec-rzyl, Spark Therapeutics) was FDA approved in December 2017 for individuals with biallelic RPE65 mutation-associated retinal dystrophy, and the first treatmentwas done March 20 at Massachusetts Eye and Ear.

Creed Pettit, a 9-year-old from Mount Dora, Florida, was diagnosed at age 2 with Leber congenital amaurosis and was legally blind due to biallelic mutation of the RPE65 gene.

A challenging procedure

In this case, Berrocal, a pediatric retina surgeon and professor of clinical ophthalmology at Bascom Palmer Eye Institute, needed to first perform vitrectomy, locate the appropriate subretinal space for the injection, and then, using a hair-thin needle, inject the modified virus directly under Pettit’s retina in his right eye during the hour-long surgery.

The medication is only viable for 4 hours before it can be injected, she said, so Pettit was put under anesthesia and the vitrectomy quickly completed. A typical vitreous in a normal 9-year-old child is thick and gelatinous, Berrocal said, but Pettit’s was more atrophic so it was easier to remove.

After removing the vitreous, Berrocal used an OCT-integrated microscope to find the subretinal space and inject the medication. As it is injected, the medication detaches the macula.

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Audina M. Berrocal, MD, of Bascom Palmer Eye Institute, performed the 1-hour gene therapy surgery in a Florida boy with Leber congenital amaurosis.Source: Shutterstock

“Finding the subretinal space where we actually inject the medication is quite difficult,” she said. “We had two syringes with the medication. With the first syringe, I could not find the right space, and we lost it; we could not inject it in the right space.”

It took a second attempt with the second syringe to place the treatment. An air-fluid exchange was then performed to remove any medication that may have been left on the retina to deter inflammation, she said.

“I’ve been texting with [Pettit’s mother] since the surgery, and both she and grandma already see changes in his vision. He’s been doing things he’s never done before. The amount of lighting he needs to look at things has changed dramatically. It amazes me,” Berrocal said. “I’ve watched many children with this disorder lose vision, but I’ve never seen the regaining of vision. If that’s what we’re seeing here, that’s going to be amazing.”

An amazing journey

Pettit’s mother was interested in enrolling him in clinical trials with Luxturna for years, but he either “could not or would not navigate the maze test used in the trial,” Berrocal said, adding that after the FDA approval, Pettit’s mother chose Bascom Palmer, part of the University of Miami Miller School of Medicine, for treatment because the procedure could be done sooner than at University of Iowa, where the trials were done.

Being able to see a patient regain vision with this disease, rather than slowly losing vision over time, has been an amazing experience, she said.

“The more we do the surgery, the better we’re going to become at this,” Berrocal said. “To me, being part of this bench to bedside story is probably the most amazing thing I’ve experienced in my career to this day. Being part of this boy’s story will simply be unforgettable. Everyone who was in the operating room with me that day, will never forget it. It was magical.”

Pettit was scheduled to undergo treatment in his left eye on March 28. – by Robert Linnehan

Reference:

Florida boy with inherited blindness first to receive FDA-approved gene therapy at Bascom Palmer. https://news.umiamihealth.org/en/boy-with-inherited-blindness-receives-fda-approved-gene-therapy/. Published March 23, 2018. Accessed March 23, 2018.

For more information:

Audina M. Berrocal , MD, can be reached at Bascom Palmer Eye Institute, 900 NW 17th St., Miami, FL 33136; email: aberrocal@med.miami.edu.

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