The Ophthalmic Project: What to expect at AAO 2023 Annual Meeting

Mark Dlugoss:

The American Academy of Ophthalmology’s annual meeting is the leading ophthalmic conference that attracts ophthalmologists from around the world. The four-day event features papers, keynote lecturers, instructional courses, and an exhibit hall, all the content focusing on the latest innovations in ophthalmology. This year’s meeting is scheduled for November 3rd through November 7th in San Francisco.

Hello, this is Mark Dlugoss, senior contributing editor for Ophthalmology 360. And welcome to The Ophthalmic Project powered by Ophthalmology 360. As viewers know, there’s a lot to discover and learn at the annual AAO meeting with innovation and discussion highlighted in all the subspecialties of ophthalmology. In today’s Ophthalmic Project, we will preview what ophthalmologists can expect in all the subspecialties of refractive surgery and cataract surgery. Joining The Ophthalmic Project to help sort through some of the important highlights of these two subspecialties is Julie Schallhorn, MD.

Dr. Schallhorn is Assistant Professor of Ophthalmology at the University of California, San Francisco. Her clinical focus is on the treatment of cataracts and diseases of the cornea. She’s also involved in research, study anterior segment disease and refractive surgery, including the role of corneal imaging in refractive surgery. Dr. Schallhorn, welcome to The Ophthalmic Project.

Julie Schallhorn, MD:

Thank you so much. Happy to be here.

Mark Dlugoss:

Good. So before we start, before we get into the meat and potatoes, I just want to maybe just start off with an introductory question about the academy itself. In an era when there are so many ophthalmic meetings throughout the year, I know you could probably be at one every weekend if you had the time, what makes the AAO meetings stand out over the rest?

Julie Schallhorn, MD:

There’s multiple things. It is the biggest meeting in ophthalmology. More people, there’s always a lot more going on. But for me, it’s two things. It’s the place where you get to see everybody that you’ve known throughout your life in ophthalmology. So your co-residents are usually there. The people that were fellows when you were a medical student are there. The residents that you trained, at least because I’m in academics, the residents I trained five years ago are there. So there’s just this huge connection of people, and it’s so great to be able to see friendly faces, catch up on life. They’ve got kids now, their kids are growing up, they moved to a new practice. And see how that progresses.

So both with colleagues and also friends that you’ve made in industry over time. So for me, that’s really, really special because friendship doesn’t follow specialty boundary. It’s not like, “Oh, all my friends are cataract surgeons. Or all my friends are cornea specialists.” No, you got friends across the spectrum and it’s real fun to see everybody there. So that for me is the special thing about Academy.

Mark Dlugoss:

Okay. Let’s jump into the meat and potatoes of our talk today. We’ll start with refractive surgery. Over the last few years, refractive surgery has been evolving quite a bit, especially with new surgical techniques and technology. Are there any presentations or events going on during refractive subspecialty and refractive in general that stand out for you to discuss?

Julie Schallhorn, MD:

Refractive Sub Days is just always just such a really, really great day because you get to hear what people are doing really around the world. In the United States, the FDA is great, it’s really good at protecting patients, but a lot of times we don’t get the newest stuff right away, so it’s really cool to hear what people are doing and what people are working on everywhere. A couple things. I think SMILE has been a huge change in the refractive market, the way we’re doing things. There are some other really exciting refractive lenticular exchange technologies coming out.

Silk from J&J Vision with their [inaudible 00:04:14] laser. I’ve demoed that before. I think they’re going to have it here again for demo at Academy. They’re going to be entering their FDA PMH study pretty soon here, and I think that is awesome. It’s a really cool laser. It has a very novel way of laying down the spot pattern, actually. It’s a really cool thing to see, so I think that’s going to be really, really neat.

I know Ziemer’s also working on a lenticular extraction technology as well, so that’ll be cool to see. Going with the lamellar femtosecond cuts, I think there’s a pretty exciting technology for therapeutic refractive surgery, and that’s the implantable stromal segments that we’re seeing that really was initially led [inaudible 00:04:56] Jacobs coming out of India, but now a lot of people are doing. So I have actually not started doing that myself, so I’m excited to learn to be able to start offering that to my keratoconus patients.

So those are two things that I’m pretty excited about for Sub Day and just with refractive surgery in general. And of course all the other stuff that’s happening. All the other people that are working on trans epithelial PRK, that are working on new ablation patterns. I think we’ll see some … Oh, one exciting thing, I think we’re going to hear it talking about Steve Wilson’s work coming out of Cleveland Clinic looking at topical losartan for treating corneal haze.

I think we’ve jumped the gun a little bit. It’s gone into clinic. I’ve actually put some patients on it because you can order it from compounding pharmacies. We need to really see some good studies, I think, to know the true benefit, when it’s best applied and the treatment course. So I am looking forward to hearing what people have been doing and then also discussing maybe moving that forward into a more formal study to really know how that’s going to best benefit patients.

Mark Dlugoss:

In the last five years, there’s been an explosion of advances in corneal transplantation. What do you see coming out of the Academy meeting in regard to some of these new surgical advances?

Julie Schallhorn, MD:

Yeah, I think you’re right. Corneal transplantation has just made huge leaps and bounds and working towards the goal that I think all corneal specialists have, which is to eliminate corneal cognitive blindness worldwide. Starting with the endothelium because I think that’s where the really exciting stuff is happening right now. We’re starting to see cultured endothelial cell transplantation become more of a reality.

There’s been outside the US studies with Orion Biotech looking at the [inaudible 00:06:58] protocol, cultured endothelial cells with a ROCK inhibitor injection. They’re starting their initial studies here in the United States coming up pretty soon, which is going to be, I think very exciting and really very excited to see their continued data from the outside of the US cohorts that have been done both in Japan and in El Salvador. So that’s very exciting.

There’s another company called MSL coming out of the Goldberg Brothers from Stanford and then East Bay here in California looking at cultured endothelial cells that are linked to magnetic nanoparticles. And then after surgery the patient puts on magnetic goggles and it kind of helps draw the endothelial cells into the correct location. They have been in studies here in the United States, so looking forward to hearing about and seeing their progress as well as they move through that. Both huge benefits to patients.

We’ve been stuck in a one-to-one donor to recipient model for a long time with corneal cell transplantation. But of course when you come to cultured cells, you can expand those cells in culture, and so one donor can treat tens to hundreds of patients. In the US, we’re so fortunate we have such a strong eye banking system that I’ve never had problems getting tissue for my patients, but once you go outside of the US, there’s a lot of cultural taboos and just cultural feelings about organ donation that my colleagues in China have five plus year waiting lists for patients getting corneal transplant.

So that I think is really going to help a lot of people worldwide with those techniques. So that’s super exciting. Outside of that, the other … And this is where I tend to live in the university, is very, very complex eyes where there’s not a lot of options. So there’s two exciting technologies that are coming out for that. One that I’m looking forward to see some of their clinical data presented. One is the EndoArt, which is an Israeli company. It’s an acrylic, a six and a half millimeter acrylic endothelial implant that the whole idea is that it just blocks aqueous ingress into an [inaudible 00:09:05] cornea.

It’s probably for patients that are outside the … that are not going to do well with traditional transplants, but those patients still have blinding disease, so that’s going to, I think be pretty cool. The nice thing about it is it’s shelf stable. You can pretty much do it anywhere. You don’t have to have the availability of a corneal transplantation bank. So I think that’s going to be pretty cool.

They’ve gotten CE mark and they’re starting their US studies pretty soon, but that’s a cool technology. There’s also a new updated take on the keratoprosthesis that I think is going to be presenting some data at academy as well, which is great for those patients that have really very difficult corneal environments to transplant corneas too. So all in all, I think that will be … It’s a great time to be a cornea specialist. There’s so much exciting stuff happening and it’s really a very tangible benefit to patients, so it feels good.

Mark Dlugoss:

Let’s move on to cataract surgery. Cataract surgery, again, another subspecialty that continues to evolve beyond phacoemulsification with new surgical approaches and like Femtosecond technology. What can eye surgeons expect to see regarding these new approaches?

Julie Schallhorn, MD:

I think that Femto, there was a huge fanfare for Femto about 10 years ago, and then I think that the downsides of that, of the Femto lasers at that time were a lot to overcome for really broad adoption. I have just been so impressed. The company that’s really continued to innovate in this field and to change things is LENSAR.

And they have taken that idea and iterated and iterated on it, and it’s getting really exciting. I think they’re going to crack the nut to make Femto a standard part of cataract surgery. I have just been loving watching them as they grow and what they they’ve been doing. At the university, we don’t have a unit and there’s lots of politics and everything involved that have precluded me from getting one, but everybody I know that’s in practice that has gotten one of their units absolutely loves it. So I think they’re a cool and exciting company when it comes to that.

I think we’re going to see continued … Outside of that, the [inaudible 00:11:47] I think continues to plug along and make revisions to make that an accepted part, and the whole standardizing those parts of cataract surgery is going to make cataract surgery, I think … And this is the dream, I think we first saw with Femot is safer and more repeatable and more repeatable outcomes.

I think we’re going to see steady progress towards that moving forward. So that’s pretty exciting with the surgical technique side of thing. We’re seeing a lot, and this is only a good thing, a lot more innovation in the phaco multiplication machines themselves. ZEISS launched the QUATERA recently. DORC has a phaco machine they’re working on. BVI has a phaco machine they’re working on. Alcon normally has a next generation phaco machine, which I have not gotten to see yet, but all exciting stuff. And when there’s more people in the market, there’s more ideas and more competition. And I think that really just spurs growth and innovation. So I am very optimistic about the future of phacoemulsification in general. I think it’s very cool.

Mark Dlugoss:

Well, both refractive and cataract surgeons, just as we were just talking about love innovation and new technique. It’s like once a new thing’s been approved, they want the next, next great thing. I’ve seen in the years I’ve covered ophthalmology, it’s probably probably the funniest thing … You just got the latest thing. You want a new one. But anyway, in this year’s exhibit hall, what can ophthalmologists expect from industry in regards to new technologies?

Julie Schallhorn, MD:

I think people are going to, in terms of approved stuff, I think that you’re going to see … Oh my gosh, it’s not even approved, but I think you’re going to see the next generation for refractive lasers are going to be out in the field for people to look at to see, maybe even to demo if you talk to them, which I think is going to be pretty exciting for refractive surgeons. I think visualization is just huge.

Heidelberg just recently got their ANTERION approved in the United States. I’m going to be really excited to look at that. That’s a beautiful, it’s an anterior segment specific OCT, and that is really important for two reasons. With anterior segment specific, it’s the fixation target is designed so that you can actually track and do repeatable imaging at the same place every time. And then also it’s a longer wavelength of light, so you can actually image more deep inside the eye versus a retinal OCT that’s been adapted to the anterior segment.

So that’s a beautiful machine. I think everybody should go check that out. I think it’s going to be really, really cool. It can do … They got to prove, to my knowledge, it’s the first one in the United States, OCT topography and for biometry as well. So that’s a very, very cool instrument. In terms of other visualization, I know that there’s this SeeLuma from BNL I’m excited to look at. It’s another collaboration between BNL with the scope, with the Heidelberg ANTERION, anterior segment OCT driver integrated into it, which will be cool.

ZEISS continues to innovate in this field as well, especially in terms of … And this is a different theme, but in terms of seamless integration from clinic into the OR in terms of information portability. LENSAR actually as well in that. So I think imaging is going to be big this year. I think we’re going to see a lot of stuff like that. I think that the new lasers, the lenticular extraction is going to be cool to look at. And then IOLs, I don’t think there’s going to be a lot of exciting IOL stuff on the show floor per se, but there’s a lot of exciting stuff in the works. So I think we’ll see that coming around maybe next year to the year after.

Mark Dlugoss:

You mentioned that the IOLs. IOLs become a very complex and challenging arena that demands incredible skill and experience. What presentations are surgeons expecting in regard to IOLs this year? In every category, there seems to be something going on.

Julie Schallhorn, MD:

Yeah, there’s a lot happening with IOLs. So I think for IOLs, there’s like the broad themes are candidacy and selection criteria for our existing IOLs. We continue to evolve and develop our knowledge of that. There’s going to be some good presentations on that. Actually, we’ve got an exciting paper looking at patient reported preoperative personality scores, and patient reported actually a PHQ2, a two item question, screening questionnaire for depression and the effect of that on patient reported outcomes after diffractive multiple IOLs.

But that’s a separate thing. So I think that’s one area that I think is exciting that’s continuing to evolve. And then there’s, I think coming, there’s the whole category of, I would say the resurgence of monovision or blended vision, whatever you want to call it with RXSight, which gives you this amazing ability to really drill in target perfect distance and that flexibility to figure out the sweet spot for near.

So I think we’re going to see some continued understanding of that. I’ve been pushing them to really look into how to step people into that monovision the best because they have so much data, and I think it’s a really interesting phenomenon as patients adjust to having that blended vision in their eyes, experiencing it at home as you go through the adjustment process. In terms of stuff that’s coming out that I think we’re going to hear a little bit about, there’s delving further into the refractive IOLs.

I think that we’re going to see continued progression in refractive extended depth to focus. J&J is going to be launching very soon their new refractive beyond the Eyhance, greater extended range of vision, refractive IOL. I think that we are going to be seeing that. We see that right now in the ISOPURE from BVI, even though it’s labeled as a monofocal IOL, but giving that extended depth of focus curve. So that’s going to be, I think a continued topic of discussion.

And then the holy grail really is the accommodating IOLs and the accommodating IOLs, they’re not at the stage right now where I think we’re going to be seeing big presentations about them. None of them are … The [inaudible 00:18:47] has had their FDA study approved, but they don’t have the data yet.

But I think that’s a continued drumbeat of innovation in terms of this, the march towards accommodating, accommodating lenses. And I think that’s going to be … We’re hear that in the undercurrent, I think of a lot of IOL talks and a lot of IOL just talk on the show floor. But I think that’s really what’s coming around the corner, and I think it’s probably pretty soon, which is exciting.

Mark Dlugoss:

Yeah, it seems like the accommodated lenses ever since they’ve come out have been like the holy grail. Some great ideas have come across so far, and what I’ve always noticed about innovation in ophthalmology is nothing goes bad. Think of the first the array lens, when that first came out and they had to extract those lenses out 20 years ago, 20 some years ago.

Julie Schallhorn, MD:

Yeah.

Mark Dlugoss:

Everybody was in an uproar, but someone took it. And I’m not naming companies, but several companies took it, took that whole concept from 3M, built on it, and here we are. All these other lenses have come about, and because of that whole concept, so nothing, at least in my view as a journalist in ophthalmology, nothing goes wrong. It just gets put on a shelf. Somebody comes by, “Hey, let’s try this,” and bingo, we have a new idea. And I think doing some research for this podcast, I’ve found that a lot of these companies are exactly doing that. They’re coming up with new ideas based on an old platform.

Julie Schallhorn, MD:

Innovation is iterative. Once in a while, you’ll have something that comes around that really breaks the mold like RXSight just took the existing mold and totally smashed it. And Kelman with Vaco to start. But innovation for a lot is a stepwise incremental process, and we learn and change something and then the next generation’s better and better and better and better.

And really, it keeps things interesting as a position because you’re always, like you said, we’re addicted to what’s new, what’s better type of thing. So you’re always looking for that, but it’s really major improvements in patient care because if you look at the metric that we use to judge success now is a lot different than the metric we used to judge success 20, 30 years ago. And the gradations that we’re getting are finer and finer because we’re really drilling in on what makes people better. So it’s very exciting.

Mark Dlugoss:

Well, with the 127th annual AAO meeting has to offer, what are you as a surgeon and researcher looking forward at this year’s meeting, and what would you recommend to your colleagues about this year’s meeting?

Julie Schallhorn, MD:

I think it’s almost like it’s become a philosophical question. Like you were saying, there’s so many meetings and now with Zoom and virtual learning, what are we going to get out of it? And for me, I am most excited, I think about seeing people I know, hearing about what they’re interested in because I learned so much from other people and other people’s experiences that … And that just gets lost in a Zoom conversation or a webinar, which are good if I want to learn a specific thing. But if I’m just like, “Hey, what’s happening? What do you doing in your practice right now?” I learn so much from seeing people in action and talking to them and that face-to-face connection.

And I always teach, I teach a couple courses. I teach the Yamane course and I teach the DMEK course. And I always learn so much from the people that come to those courses, like what they’re doing in their practice and the other instructors and seeing how they do things. And that’s the thing for me that’s the heart of it, is those chance encounters running into somebody, “Oh, you’re doing that? That’s really cool. Oh, that’s that study. Oh, how’s that going? Oh, maybe I should be a part of that study.” That type of thing. So that’s for me. Broadly, yes, I’m excited about seeing what’s new and seeing all the presentations but on a personal level, I am just excited about those small interactions that they’re kind of spontaneous and really irreplaceable.

Mark Dlugoss:

Yes. You mentioned that about all the stuff that goes on, not in the sessions or the exhibit hall. Well, in the exhibit hall sometimes it does too. But in my years I have learned so much from physicians was in meetings, having one-on-one conversations with people, and you learn so much more than what you would learn at the podium sometimes. And that’s the beauty of the Academy meeting. You have all this stuff at your disposal and just all you got to do is take advantage of it.

Julie Schallhorn, MD:

That’s exactly right. And it may not come from interior segment, it may come from something that they’re talking about in retina or it may come from something they’re talking about in uveitis. There’s a lot there, and it’s an exciting place to be.

Mark Dlugoss:

Thank you, Dr. Schallhorn. Well, that concludes today’s Ophthalmic Project podcast. I want to thank Dr. Julie Schallhorn for spending some time with me today in previewing the refractive and cataract Surgery highlights at this year’s AAO. And finally, I want to thank you, the viewers for watching. We at Ophthalmology 360 and the Ophthalmic Project really appreciate your time for viewing and for everybody, have a great AAO meeting and have a great day today.