The deep dish on all things ophthalmology at this year's AAO meeting

The American Academy of Ophthalmology (AAO) held its annual meeting at McCormick Place in Chicago, Illinois, from 18 to 21 October, 2024. Always a highlight of the year, this meeting showcases the advancements in treatments, surgical innovations, and the continued evolution of providing the best care possible for patients.

Between dining on the city’s famous Chicago-style hot dogs and deep-dish pizzas, the attendees gathered to share data and insights amongst themselves and with the Eye Care Network, who attended the meeting in person.

AAO attendees gathered in Chicago to share data and insights amongst themselves and with the Eye Care Network. Image credit: ©YOONSOO – stock.adobe.com

Dig into data

Meghan Berkenstock, MD, gave a presentation entitled, “Incidence and Prevalence of Uveitis and Associated Ocular Complications in the US TriNetX Database.” As part of the research, Berkenstock and her fellow researchers worked to examine the vast data available to better understand how common uveitis is and how ophthalmologists can better address the condition.

In her interview, she shared, “Among the 300,814 patients with uveitis, the mean age was 57 years, with a predominance of [women] who were Caucasian. Anterior uveitis was the most common subtype, and the most commonly used immunosuppressants were prednisone and methotrexate. The most commonly associated systemic disease was ankylosing spondylitis, and the most frequent complications were, in order, glaucoma or ocular hypertension, followed by macular oedema and cataract.”

The cumulative incidence rate of uveitis from 2013 to 2023 was 60 of 100,000 people, and the prevalence rate for the same period was 285 of 100,000 people. These numbers, Berkenstock said, provide a widely generalisable dataset, though she acknowledged the breadth of the database does create challenges for accurate coding.

In a presentation and subsequent interview which showcased innovation in both chambers of the eye, Michael Singer, MD, PhD, discussed chloroprocaine hydrochloride ophthalmic gel (IHEEZO; Harrow), a preservative-free, viscous anaesthetic for intravitreal injections. “Initially it was approved for use in cataract surgery, but recently it’s transitioned [to] prep for patients who want anaesthesia in intravitreal injections,” he explained. “I’ve been incorporating it into my practice over the last 5 to 6 months and had very good success.”

Singer said that in conversations with colleagues, there has been a throughline of gel anaesthetics having a “bad reputation” for an increase in endophthalmitis versus topical liquid anaesthetics. “Well, it turns out recently, there was a study that looked at the use of betadine in conjunction with the gel, as opposed to using it in conjunction with tetracaine drops,” Singer said. “What it showed was that more colonies were removed using betadine with the gel than with the drops, basically explaining that this is even safer than tetracaine drops. So what I love about the concept is we’re dispelling a myth.” He said while endophthalmitis is “the thing that basically keeps us up at night” among many ophthalmologists, the actual risk as shown in recent studies does not align with the common reputation.

Singer went on to say that in applications of the chloroprocaine gel prior to cataract surgery, within 90 seconds, patients experienced the anaesthetic effect. “A number of studies showed, over time, at three different time points, with three installations, 90 seconds later, you were able to do cataract surgery without needing any supplemental anaesthesia—[This] was really important because the tetracaine-dropped arm needed supplemental anaesthesia, while the IHEEZO did not,” Singer said. The lack of preservatives in the eye gel also makes it a more suitable anaesthetic for those with sensitivities to preservatives which may contribute to postoperative pain.

Considering the whole patient

The AAO meeting featured plenty of information from educational sessions for clinicians to put into practice immediately after the conference. One course, led by Sruthi Arepalli, MD, focused on ocular conditions related to pregnancy and postpartum care. Arepalli said the topic has been of interest to her since early on in her career.

"There are quite a few conditions that we don’t have a great algorithm for if you’re pregnant, and there’s lots of good reasons for that. It’s because we don’t want to do undue harm to the foetus or to the mother, or risk pregnancy,” she said. “But at the same time, it raises the question of what we should be doing and how we can prevent further vision loss.”

Arepalli recognised that these questions were not endemic to retina care. She worked with colleagues within cornea care, glaucoma research, neuro-ophthalmology and oncology to explore other common conditions which impact pregnant patients. Speaking about retina care, Arepalli pinpointed diabetic eye diseases, especially as related to gestational diabetes, as an area of concern for many pregnant patients.

“If you have diabetic macular oedema that sits for a long time, you worry that you’ll have long-lasting vision loss,” she said. “But the problem is that the traditional treatment for these patients are anti-VEGF, so they’re injections into the eye, and there is not good data on what that looks like for foetuses or for pregnancy, and what that looks like for breastfeeding.” Patients facing gestational diabetes need their full care team to be on board, prepared with a variety of care options that work for the needs of the pregnant patient and the baby.

Arepalli also pointed toward retinal surgery as an area where pregnant patients deserve special considerations. “If a patient comes in with a retinal detachment, you know you don’t want to delay care,” she stated. “I’ve always found that when I have a pregnant patient with a retinal detachment or someone who needs a retinal intervention, it’s a very complex discussion between them, their OB/GYN, anaesthesia, and myself.” By sharing approaches and resources, retina specialists and subspecialists in other areas can determine the safest, most efficacious care for each patient.

Meeting patients where they are

Christina Y. Weng, MD, MBA, shared insights from recent publications on teleretinal screenings for diabetic retinopathy. Her presentation was part of the Retina Ophthalmic Technology Assessment (OTA) Symposium put on by the OTA Committee.

Weng recently published an OTA alongside her committee members which focused on the importance of early detection and intervention in diabetic retinopathy. “Very unfortunately, only about 50% to 65% of patients with diabetes mellitus are actually compliant with these screening recommendations, and in fact, this rate is even lower for ethnic minorities,” Weng said. “The reasons behind these subpar numbers are multifactorial, but they include limited access to care, lack of patient awareness and, of course, socioeconomic disparities.”

Weng participates in a large teleretinal screening programme in Houston, Texas, which has screened nearly 200,000 eyes to date. Many of those patients would not have received a diagnosis or care if they did not have access to teleretinal screenings. In the OTA Weng discussed at the AAO meeting, researchers aimed to identify data published between 2006 and 2023 that illustrated the effectiveness of the screenings.

Weng narrowed down the team’s findings from these publications into four core points: teleretinal screenings demonstrated “acceptable sensitivity and good specificity” in detecting diabetic retinopathy; teleretinal screenings were not as effective for identifying macular oedema; screenings had a positive impact on diabetic retinopathy screening compliance, increasing it by more than twofold in one study; and the screenings were cost-effective and well received, with many patients expressing a preference for teleretinal screenings versus traditional surveillance methods.

All these findings support the scalability of teleretinal screening programmes, Weng said, and represent an area where retina specialists can further expand. “Our hope is that this work will encourage confidence in similar diabetic retinopathy teleretinal screening programmes, and also provide a foundation for future work as these programmes become more robust, more prevalent and more technologically sophisticated,” she said.