The deep dish on all things ophthalmology at AAO 2024

(Image credit: AdobeStock/anderm)

The American Academy of Ophthalmology (AAO) held its annual meeting at McCormick Place in Chicago, Illinois, from October 18 to 21, 2024. Always a highlight of the year, this meeting showcases 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 among themselves and with our team, who attended the meeting in person.

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 females who were [White]. 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 edema and cataract.”

We also spoke to Michael Singer, MD, who presented data that help to challenge myths regarding the use of ophthalmic gel as an anesthetic during the administration of intravitreal injections. He noted that he has seen success with the preservative-free chloroprocaine ophthalmic gel in his practice over the past 5 to 6 months that he has been incorporating the product. He noted that the research backs up his experience and “adds a lot of credibility to the fact that this is a good, safe alternative to our patients undergoing intraocular procedures, whether it be a cataract or intravitreal injections.”

Singer said that in conversations with colleagues, there has been a through line of gel anesthetics having a “bad reputation” for an increase in endophthalmitis vs topical liquid anesthetics. “It turns out [that] recently, there was a study that looked at the use of Betadine [povidone iodine] 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. What I love about the concept is we’re dispelling a myth.” He said that although endophthalmitis is “the thing that basically keeps us up at night” among many ophthalmologists, the risk as shown in findings from recent studies does not align with the common reputation.

Considering the whole patient

The AAO meeting featured plenty of 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 in her career.

“I put this course together for the AAO because as I started my career in retina and uveitis, I realized that there are quite a few conditions that we don’t have a great algorithm for if you’re pregnant, and there are lots of good reasons for that. It’s because we don’t want to do undue harm to the fetus 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 recognized 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 that affect pregnant patients. Speaking of 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 edema 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 is anti-VEGF factors, so they’re injections into the eye, and there are not good data on what that looks like for fetuses 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 said. “​​If they haven’t dealt with it before or they’re suddenly losing vision, it’s very scary to tell them that we’re going to sit on it or what our limited options are,” she said. “It’s an important topic to discuss and [for which] to have a good armamentarium of treatment options.”

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 [obstetrician-gynecologist], anesthesia, and myself.” By sharing approaches and resources, retina specialists and subspecialists in other areas can determine the safest and most efficacious care program for each patient.

Meeting patients where they are

Turning to look at technology, 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. “These OTA committees are composed of academy members from various subspecialties who evaluate drugs, procedures, and diagnostic tests for clinical effectiveness and safety,” Weng explained. The synthesized data undergo rigorous grading and review before the assessments proceed to publication.

Weng recently published an OTA alongside her committee members that 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 [adherent] with these screening recommendations, and, in fact, this rate is even lower for ethnic [minority individuals],” 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 program in Houston, Texas, which has screened nearly 200,000 eyes to date. Many of these 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 identified data published between 2006 and 2023 that illustrated the effectiveness of the screenings, defined in 1 of 3 ways. “The first was accuracy in detecting diabetic retinopathy or diabetic macular edema compared with traditional ophthalmic screening with dilated fundoscopic examination or 7–standard field ETDRS [Early Treatment Diabetic Retinopathy Study] photography,” Weng said. “The second way that we evaluated effectiveness was the impact on diabetic retinopathy screening [adherence] rates. And the third was through cost-effectiveness and patient satisfaction of teleretinal screening compared with traditional diabetic retinopathy screening.”

Weng narrowed down the team’s findings from these publications into 4 core points: teleretinal screenings demonstrated “acceptable sensitivity and good specificity” in detecting diabetic retinopathy; teleretinal screenings were not as effective for identifying macular edema; screenings had a positive impact on diabetic retinopathy screening adherence, increasing it by more than 2-fold in findings from one study; and the screenings were cost-effective and well received, with many patients expressing a preference for teleretinal screenings vs traditional surveillance methods. These findings support the scalability of a teleretinal screening program, 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 programs and also provide a foundation for future work as these programs become more robust, more prevalent, and more technologically sophisticated,” she said.