ethics and risk management corneal ectasia and refractive surgery

758 MEETING
TH
NEOS
www.neos-eyes.org
ETHICS AND RISK
MANAGEMENT
CORNEAL ECTASIA AND
REFRACTIVE SURGERY
MARCH 11, 2016
Back Bay Event Center
180 Berkeley Street
Boston, MA 02116
The 758TH Meeting
of
A Public Foundation for Education in Ophthalmology
MARCH 11, 2016
ETHICS AND RISK MANAGEMENT
including the B. Thomas Hutchinson, MD, Lecture
Deborah S. Jacobs, MD, Moderator
Carolyn Anderson, MD, Program Committee Coordinator
CORNEAL ECTASIA AND REFRACTIVE SURGERY
Samir Melki, MD, PhD, Moderator
Jonathan Talamo, MD, Program Committee Coordinator
Accreditation:
The New England Ophthalmological Society designates this live activity for a maximum
of 7 (3.5 in Risk Management) AMA PRA Category 1 Credits™. Physicians should claim
only the credit commensurate with the extent of their participation in the activity.
The New England Ophthalmological Society is accredited by the
Massachusetts Medical Society to provide continuing medical education for physicians.
Back Bay Event Center
180 Berkeley Street
Boston, MA 02116
NEOS
PO Box 9165 • Boston, MA 02114
617.227.6484 • Fax 617.367.4908
[email protected]
www.neos-eyes.org
2
MESSAGE FROM THE PRESIDENT
Once again, NEOS has had to raise membership dues to cover expenses. Dues
approval has become an almost automatic exercise every few years and passes
with little or no debate, perhaps because we all know that most business costs are
increasing. Unfortunately, this becomes especially perverse when much of our
reimbursement is declining. Opening a dues statement can now induce a feeling of
sticker shock. The cost of holding a meeting has risen astronomically. Gone are the
days when a speaker can show up with a slide carousel ready to go. Different display
formats, operating under different operating systems need to communicate with
each other. Speakers now have embedded videos and other features that require an
army of experts to run smoothly. New CME requirements necessitate interactive
audience systems. The team behind the curtain is large and growing, and expensive.
Compliance is another growing cost. CME requirements have grown more rigorous
and complicated. In addition, the days of generous and unrestricted industry support
are gone. In order to stay on the correct side of non-profit law, more extensive
accounting is necessary. This is just a partial list of the considerations guiding our
dues recommendations.
During my time on the NEOS board, we have made a number of attempts to
mitigate our costs. We have had hard negotiations with our vendors. We have
increased rental costs significantly to our industry supporters. We have sought other
venues and formats to deliver our content, but Boston is a prosperous, and therefore,
expensive city in which to operate. I offer this information not as an apology for our
decisions, but as an explanation for them. I can only thank you for your generosity
and understanding for your support as NEOS goes forward.
David Lawlor, MD
President
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GUEST OF HONOR and B. THOMAS HUTCHINSON LECTURER
Thomas S. Harbin, Jr. MD, MBA
Dr. Tom Harbin is an experienced glaucomatologist, app
developer and author. He received his BA from Vanderbilt
University and MD from Cornell University Medical College
in 1970. He served his residency at Johns Hopkins’ Wilmer
Institute followed by a glaucoma fellowship at Washington
University. He joined Eye Consultants of Atlanta in 1975
and continues to practice there. He entered the Georgia State
Executive MBA program in 1989 and received his MBA in 1991. He served on
the clinical faculty at Emory for 20 years and currently holds the title of Emeritus
Clinical Professor.
He published Waking Up Blind: Lawsuits over Eye Surgery in 2009 to wide acclaim,
a book that is used to teach medical ethics in many ophthalmology residency
programs. He later published The Business Side of Medicine… What Medical Schools
Don’t Teach You and still later, with co-developer Dr. Scott Pastor, an app to aid in
eyedrop compliance, EyeDROPS.
Recent lectureships include delivering the keynote address at the Henry Ford Health
System’s annual meeting of the Department of Ophthalmology and the Susruta
Lecture at the Wilmer Residents Annual Meeting. He has served as President of the
Georgia Society of Ophthalmology and Trustee at Large of the American Academy
of Ophthalmology. He chaired the board of Piedmont Hospital and Piedmont
Healthcare System in Atlanta and joined the Academy’s Senior Ophthalmologist
Committee in 2015. He served as board chairman of the Georgia State chapter of
The Nature Conservancy from 2013 to 2015.
Dr. Harbin lives in Atlanta with his wife Ellen. They have two children and five
grandchildren.
PREVIOUS HUTCHINSON LECTURERS:
Richard L. Abbott, MD
John W. Shore, MD
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B. THOMAS HUTCHINSON LECTURE
B. Thomas Hutchinson, MD
Dr. Thomas Hutchinson was born in Flatwoods, West Virginia.
After graduating from West Virginia University where he was
elected to Phi Beta Kappa, he received his medical degree from
Harvard Medical School. Following internship at Pennsylvania
Hospital in Philadelphia and two years in the Public Health
Service, Dr. Hutchinson returned to Boston for a fellowship
in the Howe Laboratory, Harvard Medical School, a residency
in ophthalmology and a fellowship in glaucoma at the Massachusetts Eye and Ear
Infirmary.
He is a founding partner of Ophthalmic Consultants of Boston. He is a past president
of the American Academy of Ophthalmology, past chair of the Advisory Board of the
Foundation of the AAO, and has served as a member of the AAO Board of Trustees
and the Foundation Advisor Board. In addition, Dr. Hutchinson has served as the
first Secretary of Ophthalmic Practice. He has served for 9 years as a director and one
as chairman of the American Board of Ophthalmology as well as a director of OMIC.
As an Associate Clinical Professor of Ophthalmology at Harvard Medical School, he
has for over 40 years maintained an active role in the teaching of medical students
and residents. He has trained over 100 ophthalmic fellows in the subspecialty
management of glaucoma and cataract. For many years he was the director of the
Harvard Post-Graduate Course and for 10 years was the assistant chief editor of
Archives of Ophthalmology. Dr. Hutchinson was a founding officer and is a past
president of the Massachusetts Society of Eye Physicians and Surgeons, past president
of the Society to Prevent Blindness-Massachusetts, and a past president of the New
England Ophthalmological Society. He is also a member of the American Glaucoma
Society and a founding director and past president of the Chandler-Grant Glaucoma
Society. Dr. Hutchinson is the author of multiple peer reviewed articles, editorials,
and book chapters, and has lectured extensively.
His professional interests also include quality assurance, credentialing and public
service programs, and for 25 years Dr. Hutchinson was the founding Chairman of
AAO’s Eye Care America, the largest public service program in American medicine.
Dr. Hutchinson has received multiple awards, including the AAO Senior Honor
Award, the Lifetime Achievement Award, and the Distinguished Service Award, as
well as being Guest of Honor at the Academy’s 100th anniversary. In addition, he has
been Man of the Year from NEOS as well as numerous regional and national awards.
Dr. Hutchinson’s constant dedication to quality of care and ethical medicine has
been a pillar of quality in local, regional and national ophthalmology.
5
GUEST OF HONOR
J. Bradley Randleman, MD
Dr. Bradley Randleman is the John H. and Helen S. Hughes
Professor of Ophthalmology at Emory University School
of Medicine, Director of the Cornea, External Disease, &
Refractive Surgery Section at the Emory Eye Center & Emory
Vision, and Editor-in-Chief for the Journal of Refractive Surgery.
A widely respected cornea specialist, his areas of expertise
include: corneal and intraocular refractive surgical procedures
including LASIK and premium laser-assisted cataract and IOL surgery, complicated
cataract surgery, and the management of corneal ectatic disorders. His primary
research interests include preoperative refractive surgical screening, the avoidance,
diagnosis, and management of refractive surgical complications, diagnosis and
management of corneal ectatic disorders, and refractive cataract surgery.
Dr. Randleman received his BA degree from Columbia College at Columbia
University in New York City, his M.D. degree from Texas Tech University School
of Medicine in Lubbock, Texas, where he was elected to the Alpha Omega Alpha
medical honor society in his junior year, followed by his Ophthalmology residency
at Emory University in Atlanta, Georgia. Dr. Randleman joined the Emory faculty
and served as Assistant Residency Director for two years while also completing a
fellowship in Cornea/External disease, and Refractive Surgery at Emory University.
In 2004 he joined the Emory faculty full-time as an Assistant Professor, served as the
Director of the Emory Corneal Fellowship program from 2006 through 2012, and
took over as Director of the Cornea Service in 2012.
Dr. Randleman has been awarded the Claes Dohlman Fellow Award (2004), the
inaugural Binkhorst Young Ophthalmologist Award from the American Society
of Cataract and Refractive Surgery (2010), the Kritzinger Memorial Award from
International Society of Refractive Surgery (2011), and received the Secretariat Award
(2007), Achievement Award (2008) and Senior Achievement Award (2014) from the
American Academy of Ophthalmology, and the Inaugural ISRS Recognition Award
(2015).
Dr. Randleman has served as Editor-in-Chief for the Journal of Refractive Surgery
since 2011. He has authored more than 100 peer-reviewed publications in leading
ophthalmology journals in addition to 30 book chapters on Refractive Surgery
evaluation and management of complications and IOLs, and has authored two other
texts, Collagen Cross-Linking (2013), which he co-edited on Farhad Hafezi, MD,
PhD, and Refractive Surgery: An Interactive Case-Based Approach (2014).
6
Morning Session
ETHICS AND RISK MANAGEMENT
Deborah S. Jacobs, MD, Moderator
Carolyn Anderson, MD, Program Committee Coordinator
Using feedback from NEOS members and discussion by the Program Committee,
ethics of introducing new procedures to one’s practice was identified as a significant
professional practice gap in our membership.
Program Objectives: The content and format of this educational activity has been
specifically designed to fill the identified practice gaps in our membership's current
and potential scope of professional activities in a way that focuses on education, while
managing commercial support and maintaining independence from promotional
activities and commercial proprietary interests. This program seeks to:
1) Increase the competence of the audience in the areas of strategies for MD as defendant in malpractice claims.
2) Improve the performance of the audience in ethics of introducing new procedures
to one’s practice.
3) Improve outcomes in the area of addressing conflict of interest in medical innovation and research.
8:30 am Introduction and Welcome .....................................Deborah S. Jacobs, MD
8:35 8:55
9:15 9:25
9:35
9:45
10:00
10:30
10:40
10:50
10:55
Diagnostic Errors: Retinal Detachments,
Including Perspectives from OMIC............................ Trexler Topping, MD
Your Duty to Disclose Medical Mistakes: Perspectives from
a Medical Malpractice Defense Attorney......................Stephen O’Shea, Esq
Ethics as Part of Residency Training:
Is it One of the “Competencies”?.................................. Carolyn Kloek, MD
Ethics of Adopting a New Surgical Technique...... Samir Melki, MD, PhD
Ethics of International Ophthalmology........................Geoffrey Tabin, MD
Business Meeting
Refreshment Break and Exhibits
Medicine Heal Thyself:
The Role of Medical Boards....................................Maroulla Gleaton, MD
Conflict of Interest in Medical
Innovation and Research...................................................Joan Miller, MD
Introduction of Guest of Honor and B. Thomas Hutchinson
Lecturer Tom Harbin, MD, MBA...........................Deborah S. Jacobs, MD
Hutchinson Lecture: Ethical Lessons
from “Waking Up Blind”......................................Tom Harbin, MD, MBA
(Continued on page 8)
7
11:20
11:45
Panel Discussion and Questions .......... Deborah S. Jacobs, MD, Moderator
Maroulla Gleaton, MD
Stephen O’Shea, Esq.
Tom Harbin, MD, MBA
Geoffrey Tabin, MD
Carolyn Kloek, MD
Trexler Topping, MD
Joan Miller, MD
Luncheon Break
LUNCHEON SEMINARS:
I.
II.
The Fragility of Knowledge,
Dr. Bradley Randleman – Freedom Room
Business Side of Medicine: What Medical Schools Don’t Teach You
Dr. Tom Harbin – Patriot Room
BE SURE TO SCAN IN FOR LUNCH BEFORE GOING TO ROOM TO RECEIVE CREDIT
BE SURE TO RETURN YOUR AUDIENCE RESPONSE UNIT BEFORE LEAVING THE BUILDING!
8
Afternoon Session
BE SURE TO RESCAN FOR AFTERNOON SESSION FOR CME CREDITS
CORNEAL ECTASIA AND REFRACTIVE SURGERY
Samir Melki, MD, PhD, Moderator
Jonathan Talamo, MD, Program Committee Coordinator
Using feedback from NEOS members and discussion by the Program Committee,
corneal ectasia and refractive surgery was identified as a significant professional
practice gap in our membership.
Program Objectives: The content and format of this educational activity has been
specifically designed to fill the identified practice gaps in our membership's current
and potential scope of professional activities This program seeks to educate attendees:
1) To learn about the latest tools and parameters to screen refractive surgery
candidates.
2) To explore alternatives for patients at risk for post-refractive surgery ectasia.
3) To review current status of corneal cross-linking in preventing and treating corneal
ectasia.
1:00 pm Introduction...........................................................Samir Melki, MD, PhD
1:05
1:15
1:25
1:30
1:55
2:25
2:35
2:45
Update on Corneal Topography.............................Kambiz Negahban, MD
Emerging Technologies to Assess Corneal Biomechanics.... Andy Yun, MD
Introduction of Guest of Honor,
J. Bradley Randleman, MD....................................Samir Melki, MD, PhD
Preventing Ectasia through Better Screening.....J. Bradley Randleman, MD
Refreshment Break/Exhibit
Update on Corneal Ectasia:
Risk Factors and Management........................................John Frangie, MD
My Patient Got Ectasia: Non-Refractive Surgeon
Approach to the Corneal Ectasia Patient...........................Paul Pender MD
Non-surgical Treatment and
Rehabilitation in Post-LASIK Ectasia .........................Deborah Jacobs, MD
3:00
Collagen Cross-linking to Treat and
Prevent Ectasia..................................................J. Bradley Randleman, MD
3:25
Panel Discussion and Questions........... Samir Melki, MD, PhD, Moderator
John Frangie, MD
Paul Pender, MD
Deborah Jacobs, MD
J. Bradley Randleman, MD
Kambiz Neghaban, MD
Andy Yun, MD
4:00Adjourn
Views expressed at NEOS meetings are not necessarily those of NEOS but represent
the view of the individual speaker, without implied endorsement by NEOS.
9
8:35 AM
DIAGNOSTIC ERRORS: RETINAL DETACHMENTS,
INCLUDING PERSPECTIVES FROM OMIC
Trexler Topping, MD
Boston, MA
Objective: Identify the most frequent types of malpractice lawsuits related to
diagnostic errors in ophthalmology; Clarify the factors that don't contribute to delay
in diagnosis of retinal detachment; Develop a differential diagnosis.
A large number of malpractice lawsuits against ophthalmologists allege a delay or
failure in diagnosis. The talk will present the preliminary results on an ongoing
project analyzing these diagnostic error claims. The focus of the talk will be on
retinal detachment. Actual lawsuits will be used to pinpoint actions eye surgeons can
take to reduce the likelihood of a delay in diagnosis.
References:
Graber M. Diagnostic Errors in Medicine: A Case of Neglect. Comm J Qual Patient
Saf; 2005;31:106-13.
National Academies of Sciences, Engineering and Medicine. 2015 Improving
diagnosis in health care. Washington, DC: The National Academies Press.
Off-label use: Possible use of bevacizumab in clinical usage.
10
8:55 AM
YOUR DUTY TO DISCLOSE MEDICAL MISTAKES:
PERSPECTIVES FROM A MEDICAL MALPRACTICE DEFENSE ATTORNEY
Stephen O'Shea, Esq.
Martin, Magnuson, McCarthy & Kenney
Boston, MA
Objective: To better understand the requirement and rationale for full, honest
disclosure to patients and/or their families when medical mistakes occur.
In Dr. Harbin’s book, Waking Up Blind: Lawsuits Over Eye Surgery, a doctor
mistakenly performed a corneal transplant, cataract extraction, and IOL implantation
on a patient’s healthy left eye, instead of the right. After surgery, the fellow, following
the instructions of the attending physician, reportedly told the patient that: “we
decided to operate on the left eye”; leaving the patient to believe no mistake had been
made during the surgery. That happened in 1983, when such a lie (not under oath)
was technically “legal”. On November 4, 2012, the Massachusetts Legislature enacted M.G.L. c. 233, §60L
(Massachusetts’ Disclosure, Apology, & Offer statute), which imposes a duty upon a
health care provider to fully inform a patient and/or his family about an unanticipated
outcome when the “unanticipated outcome involves a significant medical complication
resulting from the providers mistake.” We will review and analyze the impact that
statute and similar statutes in other states may have upon your “right to remain
silent”. We will also analyze some potential legal ramifications of full disclosure v.
failure to disclose medical mistakes to understand why many risk managers, insurance
companies, and lawyers now support full, honest disclosure in appropriate cases.
References:
Hafemeister, T, Spinos, S, Lean on Me: A Physician's Fiduciary Duty to Disclose an
Emergent Medical Risk to the Patient, 86 Wash.U.L.Rev. 1167 (2009).
Cook, AF, Hoas, H, Handbook for Rural Health Care Ethics: A Practical Guide
for Professionals, Ch. 12 Ethics Conflicts in Rural Communities: Recognizing and
Disclosing Medical Errors (2009).
Kohn, LT, Corrigan, JM, Donaldson, MS, To Err Is Human: Building a Safer Health
System, Washington, DC, National Academy Press (2000).
11
9:15 AM
ETHICS AS PART OF RESIDENCY TRAINING:
IS IT ONE OF THE “COMPETENCIES”?
Carolyn Kloek, MD
Massachusetts Eye and Ear Infirmary
Boston, MA
Objective: To define the ethical challenges facing ophthalmology residents as well as
the role of the residency program in preparing residents for ethical challenges they
may face in their careers.
The learning curve in ophthalmology residency is steep. In 3 years residents must
not only learn the medical and surgical management of ophthalmology but also
demonstrate proficiency in other competencies including interpersonal skills and
communication, professionalism, practice based learning and improvement, and
systems based practice. The trainee is in a position in which, at some point in the
course of training, he or she will need to navigate ethical problems or dilemmas
including managing the limits of one’s skills, obtaining patient consent for procedures,
coping with surgical complications, respecting patient’s wishes, and addressing the
performance of others perceived to be inappropriate. Residency programs must
recognize that residents will encounter such situations during training and provide
education and support in navigating these often challenging scenarios during
training as well as prepare the resident for future ethical challenges he or she may
encounter during their career.
References:
McDougall R. The junior doctor as ethically unique. J Med Ethics. 2008;34:268–270.
McDougall R, Sokol DK. The ethical junior: a typology of ethical problems faced by
house officers. J R Soc Med. 2008 Feb;101(2):67-70.
Helft PR, Eckles RE, Torbeck L. Ethics education in surgical residency programs: a
review of the literature. J Surg Educ. 2009;66(1):35-42.
12
9:25 AM
ETHICS OF ADOPTING A NEW SURGICAL TECHNIQUE
Samir Melki, MD, PhD
Brookline, MA
Objective: To review the ethical implications of performing a new surgical procedure.
Adopting a new surgical technique raises ethical and legal issues. The surgeon should
carefully navigate a new unfamiliar area balancing patient safety with his/her own
medico-legal protection. The process starts with a candid examination of the
motivation behind adopting the new technique ensuring an ethical balance of patient/
surgeon benefit. The next step is a critical examination of available evidence to
evaluate the risk/benefit ratio of the procedure. Once a decision is taken to adopt the
new technique, a structured plan should be designed to ensure adequate training,
proper patient education as well as disclosure. Resources should be made available to
manage intraoperative as well as postoperative complications.
References:
Eur J Vasc Endovasc Surg. 2008 Sep;36(3):253-7. doi: 10.1016/j.ejvs.2008.05.006.
Epub 2008 Jun 30.When does the 'learning curve' of innovative interventions become
questionable practice? Healey P1, Samanta J. Ann Surg. 2007 Apr;245(4):507-13.
Disclosure of individual surgeon's performance rates during informed consent: ethical
and epistemological considerations. Burger I1, Schill K, Goodman S. Am J Obstet
Gynecol. 1997 Jun;176(6):1293-8; discussion 1298-9.
New surgical procedures: can our patients benefit while we learn? Gates EA1.
13
9:35 AM
ETHICS OF INTERNATIONAL OPHTHALMOLOGY
Geoffrey Tabin, MD, MA
University of Utah
Salt Lake City, UT
Objective: I will discuss ethical issues surrounding working in international
ophthalmology development and mission based volunteer surgery in the developing
world.
There are many benefits to working as a volunteer in international eye care
development both for the visiting doctor and to the people and physicians that are
visited. However, sometimes, despite the best of intentions, short term missions can
create problems and ethical dilemmas. We will discuss many of the possible pitfalls
of medical volunteerism and how to avoid doing harm. Most ethicists would agree
that going to a foreign country to learn a new procedure is wrong. However, harm
can also be done if a complication happens and no doctor is present to manage the
patient after the visiting doctor leaves. This is an unfortunately common result of
performing keratoplasty abroad. Another ethical dilemma is of foreign doctors
performing surgery undermining the confidence in local doctors. Visiting surgeons
may also perform free surgery on patients who might otherwise pay the local doctor
for services resulting in decreased sustainability for ongoing care. We will discuss how
to work effectively within the local care system to maximize the benefit for all. We
will also explore the ethics of performing clinical research abroad.
References:
DeCamp M. Ethical review of global short term medical volunteerism. HAC
Forum, 2011.
14
10:30 AM
MEDICINE HEAL THYSELF: THE ROLE OF MEDICAL BOARDS
Maroulla Gleaton, MD
Atlee Gleaton Eye
Augusta, ME
Objective: To demonstrate how State Medical Boards play an important role in
maintaining appropriate standards of professionalism and ethics.
A review of the systems, policies, guidelines, rules, statutes, and disciplinary actions
of the Maine Board of Licensure in Medicine (MBOLIM), which is composed of six
physicians, three public members, and one physician assistant.
The MBOLIM maintains appropriate standards of professionalism and ethics by: (1)
Educating licensees and prospective licensees; (2) establishing rules; (3) Requiring
remediation; and (4) Imposing discipline.
State Medical Boards play an active role in setting and maintaining appropriate
standards of professionalism and ethics. The MBOLIM accomplishes this by proactive and reactive measures designed to educate licensees and prospective licensees
regarding professionalism and ethics, and by imposing discipline when licensees
engage in egregious unprofessional or unethical conduct.
15
10:40 AM
CONFLICT OF INTEREST IN MEDICAL INNOVATION AND RESEARCH
Joan Miller, MD
Massachusetts Eye and Ear Infirmary
Boston, MA
Objective: To review the evolving discourse on conflicts of interest in medical
innovation and research, and approaches to align and manage these different interests
for investigators, trainees, institutions and sponsors.
The primary goal of medical innovation and research is to bring therapies and cures
to patients. However, there are other interests, mostly financial, but also success and
publicity, for both individuals and institutions. The public is particularly sensitized
to the influence of financial interests, and the potential for harm to patients. As a
result, there has been a proliferation of policies and regulations designed to minimize
or manage these conflicts. As these policies evolve, we need to align and manage
secondary interests with the primary goal of benefiting patients. Disclosure of financial
interest is essential but not sufficient, and management plans may be required to
mitigate the risk of bias. Trainees involved in research need to be informed of any
secondary interest, and oversight provided. Finally, investigators must remain free to
disseminate research findings, both positive and negative, in order to preserve their
intellectual integrity and serve the public.
References:
Cappola AR, FitzGerald GA. Confluence, Not Conflict of Interest. Name Change
Necessary. JAMA. 2015 314:1791-2.
Wright BD, Merrill SA. Industry-funded Academic Inventions Boost Innovation. Nature.
2014 507:297-299.
Anderson TA, Dave S, Good CB, Gellad WF. Academic Medical Center Leadership
on Pharmaceutical Company Boards of Directors. JAMA. 2014. 311:1353-4. and
Comment. Relman AS. JAMA 2014 312:558.
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B. THOMAS HUTCHINSON LECTURE
10:55 PM
ETHICAL LESSONS FROM “WAKING UP BLIND”
Thomas Harbin, MD, MBA
Atlanta, GA
Objective: Describe the consequences of unethical behavior on eye patients.
Waking Up Blind, Lawsuits Over Eye Surgery is the story of blinded eyes and the
hospital politics that allowed it. With the use of court documents, transcripts of
tape-recorded conversations, interviews, and personal observation Tom Harbin,
MD, MBA, in a book published in 2009, described events that occurred decades
earlier. Six years after publication, Dr. Harbin will present a brief outline of the book,
the most common questions he is asked, and his perspectives on the ethical lessons
to be learned.
Reference:
Harbin T. Waking Up Blind. Minneapolis: Langdon Street Press, 2009.
17
1:05 pm
UPDATE ON CORNEAL TOPOGRAPHY
Kambiz Negahban, MD
Easton Eye Consultants
North Easton, MA
Objective: Object of the talk is give the audience a brief history of corneal topography,
it’s major impact on detecting corneal ectatic diseases, and the role it still plays in
diagnosing, and managing corneal diseases.
Understanding current diagnostic available technology for characterizing the cornea preoperatively is a fundamental pillar for assessing ectasia in normal corneas or
prior to corneal/refractive procedures. Even with advanced diagnostic techniques of
Scheimpflug tomography, epithelial mapping with AS-OCT, corneal topography remains as an essential adjunct to accurate ectasia detection. It’s long track record, availability, affordability, and reproducibility is well known. Additionally, ophthalmologists are familiar with the pattern recognition of ectatic diseases. Placido disc-based
corneal topography is sensitive enough to detect abnormal front curvature patterns
of ectatic disease in patients with relatively normal distance corrected visual acuity
and unremarkable biomicroscopy. The ERSS developed by Randleman has abnormal
topography as the most important risk factor for development of ectasia. This talk will
also discuss the basics of corneal topography, advantages, shortcomings, and some of
the objective indices (Rabinowitz I/S, KISA index) used to assess risk of ectasia.
Reference:
Rabinowitz YS. Keratoconus; Survery of ophthalmology. 1998; 42; 297-319.
Matalia H, Swarup R. Imaging modalities in keratoconus. Indian Journal of
Ophthalmology. 2013; 61 (8): 394-400.
Ambrosio R Jr, Klyce SD, Wilson SE. Corneal Topographic and pachymetric
screening of Keratorefractive patients. Journal of Refractive Surgery. 2013;29
(11);770-775
18
1:15 PM
EMERGING TECHNOLOGIES TO
ASSESS CORNEAL BIOMECHANICS
S. H. Andy Yun, MD
Cambridge, MA
Objective: To learn emerging instruments capable of assessing the global and local
viscoelastic properties of the cornea for improved management of corneal ectasia risk
and treatment.
The organization of collagen fibers in the cornea provides the mechanical strength
that is essential to support the load and to maintain the normal corneal shape. A
degradation of the mechanical strength can thus result in a change of the corneal
shape, driving ectatic disorders such as keratoconus. Genetic and molecular studies
indicated the links to the disintegration of collagen extracellular matrix. Keratoconus
explants showed disrupted collagen orientation and decreased mechanical modulus.
Similar findings have been observed in corneas that developed ectasia after refractive
surgery. Current diagnosis of keratoconus and screening for keratorefractive surgery
primarily relies on the geometrical features, such as corneal curvature and thickness.
However, the morphological information alone has been insufficient for definitive
diagnosis of early stages of keratoconus and ectasia risk in refractive surgery. In this
talk, we will overview a few techniques including those based on optical coherence
tomography and Brillouin microscopy for measuring the biomechanical properties of
the cornea and share our current insight into how these emerging technologies may
be used to improve the management of corneal ectasia risk and treatment.
References:
Girard MJA, Dupps WJ, Mani B, Scarcelli G, Yun SH, Quigley HA, Sigal IA,
Strouthidis NG. Translating ocular biomechanics into clinical practice: current state
and future prospects. Current Eye Research 2015;40:1-18
Scarcelli G, Besner S, Pineda R, Kalout P, Yun SH. In vivo biomechanical mapping
of normal and keratoconic corneas. JAMA Ophthalmology 2015;133:480-482
19
1:30 PM
PREVENTING ECTASIA THROUGH BETTER SCREENING
J. Bradley Randleman, MD
Emory University
Atlanta, GA
Objective: To discuss the latest scientifically validated methods for indivudalized
patient screening for ectasia risk.
Most patients who develop ectasia after laser in situ keratomileusis (LASIK) have, in
retrospect, had identifiable risk factors, particularly irregular topographic patterns,
that placed them at higher risk preoperatively. Some present with normal appearing
corneal topographies. Postoperative corneal ectasia occurs from a reduction in
biomechanical integrity below the threshold required to maintain corneal shape
and curvature. This threshold appears different for different eyes. As corneal tensile
strength is not uniform throughout the central corneal stroma, with a progressive
weakening in the deeper 60%, the relative extent of biomechanical alteration
after refractive surgery, expressed as depth, definitely plays a role in postoperative
weakening. Flap thickness factors directly into this alteration, as the anterior lamellar
flap does not contribute significantly to postoperative corneal tensile strength. There
is an integrated relationship between preoperative corneal thickness, ablation depth,
and flap thickness in determining the relative amount of biomechanical change that
has occurred after a LASIK procedure. A novel metric, the Percent Tissue Altered
(PTA) accounts for this integration and provides a more individualized and robust
screening metric than any of the factors in isolation.
References:
Santhiago MR, Wilson SE, Smadja D, Randleman JB. Relative contribution of flap
thickness and ablation depth to the percent tissue altered (PTA) in post-LASIK
ectasia. J Cataract Refractive Surg. 2015;41:2493-2501.
Santhiago MR, Smadja D, Gomes BF, Mello GR, Monteiro MLR, Wilson SE,
Randleman JB. Association between the Percent Tissue Altered and Post-Laser in
situ keratomileusis Ectasia in Eyes with Normal Preoperative Topography. Am J
Ophthalmol. 2014 Jul; 158:87-95.e1. [Epub Apr 10 2014].
Randleman JB, Akhtar J, Lynn MJ, Ambrosio R Jr, Dupps WJ Jr., Krueger RR,
Klyce SD. Comparison of Objective and Subjective Refractive Surgery Screening
Parameters Between Regular and High Resolution Scheimpflug Imaging Devices.
J Cataract Refract Surg 2015; 41:286-294. [Epub Dec 20 2014].
20
2:25 PM
UPDATE ON CORNEAL ECTASIA:
RISK FACTORS AND MANAGEMENT
John Frangie, MD
Pioneer Valley Ophthalmic Consultants
Greenfield, MA
Objective: The objective of this presentation is to acquaint the audience with
alternative treatments that may be offered to patients who may not be optimal
candidates for LASIK.
Corneal ectasia following refractive surgery is one of the most concerning, yet poorly
understood phenomena. The condition is recognized as progressive corneal steepening
and thinning following routine surgery upon a cornea of acceptable thickness and
contour (assuming the contralateral cornea is likewise "normal"). The onset of ectasia
is highly variable - from days to years after the procedure. A debate exists as to
whether surgical intervention compromises a biomechanically stable cornea, or if the
ectasia is the the manifestation of an undetected preexisting pathology. Given the
potential for morbidity, risk stratification systems and formulae have been proposed
to act as guidelines to "rule out" prospective higher risk patients.
This presentation will review some of the risk profiles for postoperative ectasia.
Additionally, a summary of the therapeutic alternatives for higher risk candidates
will be reviewed.
References:
Geggel HS et al. Delayed onset keratectasia following in situ keratomileusis.
J Cataract Refract Surg 199;582-586.
Randleman JB et al. Risk factors and prognosis for ectasia after LASIK.
Ophthalmology 2003;110:267-275.
Santiago MR et al. Association between the percent tissue altered and post-laser in
situ keratomileusis in eyes with normal preoperative topography. AM J Ophthalmol
2014; 158(1): 87-95.
21
2:35 PM
MY PATIENT GOT ECTASIA:
NON-REFRACTIVE SURGEON APPROACH TO
THE CORNEAL ECTASIA PATIENT
Paul Pender, MD
NH Eye Associates
Manchester, NH
Objective: Following this presentation, the comprehensive ophthalmologist will
understnd basic diagnostic and therapeutic considerations for corneal ectasia,
including treatments designed to alter progression of this condition.
Ectasia may result from both naturally occurring thinning of the cornea and from
iatrogenic causes. Findings from journal publications and case reports will be used
to illustrate key points in a rapidly evolving field that seeks to stabilize or to re-shape
the cornea in order to improve both uncorrected and best corrected visual acuity.
References:
Gomes JA et al. Global consensus on keratoconus and ectatic diseases. Cornea. 2015;
34 (4): 359-369.
Vega-Estrada et al. Keratoconus progression after intrastromal corneal ring segment
implantation in young patients: Five-year follow up. J Cataract Refract Surg. Vol 41,
June 2015:1145-1152.
Focal Points: Corneal Collagen Crosslinking, AAO, Vol.33 No. 11. November 2015:
1-16.
Off-label use: Corneal collagen cross-linking
22
2:45 PM
NON-SURGICAL TREATMENT AND REHABILITATION
IN POST-LASIK ECTASIA
Deborah S. Jacobs, MD
Boston Foundation for Sight
Needham, MA
Objective: The objective of this presentation is to provide an update on the use of
contact lenses in the management of post-LASIK ectasia.
The last two decades have brought advances in materials and manufacturing
of contact lenses as well as greater appreciation of the role of contact lenses for
therapeutic indications. This presentation is an update on the use of contact lenses in
the management of patients with post-LASIK ectasia, sometimes called keratectasia.
Advances in RGP corneal lenses, soft lenses, hybrid lenses, scleral lenses, and PROSE
treatment will be reviewed. Clinicians who encounter patients with complications
after corneal refractive surgery should be aware of advances in contact lenses that
allow for rehabilitation of patients who might have previously failed contact lenses or
been considered poor contact lens candidates. References:
Choi HJ, Kim MK, Lee JL. Optimization of contact lens fitting in keratectasia patients
after laser in situ keratomileusis. J Cataract Refract Surg. 2004 May;30(5):1057-66.
Abdalla YF, Elsahn AF, Hammersmith KM, Cohen EJ SynergEyes lenses for
keratoconus 2010 Cornea 29:5-8.
Baran I, Bradley JA, Alipour F, Rosenthal P, Jacobs DS PROSE treatment of corneal
ectasia. Cont Lens Anterior Eye 2012; 35:222-227.
23
3:00 PM
COLLAGEN CROSSLINKING TO TREAT AND PREVENT ECTASIA
J. Bradley Randleman, MD
Emory University
Atlanta, GA
Objective: To discuss the latest advances and applications for corneal cross-linking in
patients with ecatic corneal disorders.
Since the advent of corneal cross-linking using the Standard Dresden protocol there
have been multiple protocol modifications with varying success. Among the most
interesting are accelerated treatment protocols. Utilizing the concepts from the
Bunson-Roscoe Law of reciprocity, which states that alterations to the protocol in
terms of UV intensity and duration should yield equivalent results as long as the same
total dose or irradiance is delivered, these protocols have been employed, in some
instances with limited validation studies.
There are a handful of proof-of-concept studies that show varying relative results for
accelerated treatments up to 40mW/cm2; beyond that threshold limited cross-linking
occurs in vitro. However, there is controversy in the literate as to the relative efficacy
of the more accelerated of these protocols.
The corneal stromal demarcation line has been used as a surrogate for cross-linking
effect and efficacy. Accelerated protocols using epithelial removal (epi-off) have been
found to generate comparable demarcation lines as compared to the standard protocol,
while transepithelial approaches, known to be less efficacious, generate a much less
distinct demarcation line.
Clinical outcomes for accelerated protocols are mush less robust in the literature to
date, with only a limited number of small studies reporting short-term outcomes.
However, to date, these reports have been positive and comparable to results found
with the Standard Protocol.
References:
Randleman JB, Khandelwal SS, Hafezi F. Corneal Cross-Linking. Survey of
Ophthalmology 2015 Nov-Dec;60(6):509-23 [Epub ahead of print].
Hallahan KM, Rocha KM, Roy AS, Randleman JB, Stulting RD, Dupps WJ. Effects
of corneal crosslinking on ocular response analyzer waveform-derived variables in
keratoconus and post-refractive surgery ectasia. Eye Contact Lens 2014:Nov;40:339-44
Vinciguerra P, Randleman JB, MD, Romano V et al. Transepithelial Iontophoresis
Corneal Collagen Cross Linking For Progressive Keratoconus: Initial Clinical
Outcomes. J Refract Surg 2014; 30:746-53.
24
FINANCIAL DISCLOSURE INFORMATION
As a provider accredited by the Massachusetts Medical Society, NEOS must ensure
balance, independence, objectivity, and scientific rigor in all its individually and
jointly provided educational activities. All individuals in a position/role to control
the content of an activity are expected to disclose to NEOS any relevant financial
relationships they and their spouse/partner have with commercial interests.
The ACCME defines a commercial interest as any entity producing, marketing, reselling
or distributing health care goods or services consumed by, or used on, patients. Relevant
financial relationships are financial relationships in any amount, which occurred in
the twelve-month period preceding the time that the individual was asked to assume
a role controlling content of the CME activity, and which relate to the content of the
educational activity.
Financial relationships are those relationships in which the individual benefits by
receiving a salary, royalty, intellectual property rights, consulting fee, honoraria,
ownership interest (e.g., stocks, stock options or other ownership interest, excluding
diversified mutual funds), or other financial benefit. Financial benefits are usually
associated with roles such as independent contractor (including contracted research),
consulting, promotional speaking and teaching, membership on advisory committees
or review panels, board membership, and other activities for which remuneration
is received or expected. The MMS/ACCME considers relationships of the person
involved in the CME activity to also include financial relationships of a spouse or
partner.
Bradbury, Michael:
Ownership Interest: Regeneron, Chase and Associates, Inc
(Iviews imaging system)
Duker, Jay:
Consulting Fees: Alcon/Novartis, CoDa Therapeutics, Thrombogenics,
Allergan, Lumenis, Santen
Contracted Research: Carl Zeiss Meditec, Optovue
Ownership Interest: Hemera Biosciences, EyeNetra, Ophthotech
Other Types - Eleven Biotherapeutics (Board of Directors)
Heier, Jeffrey
Consulting Fees: Aerpio, Alcon/LPath, Allergan, Avalanche, Bayer, Dutch Ophthalmics, Endo Optiks, EyeGate, Foresight Biotherapeutics,
Forsight Vision4, Genentech, Heidelberg Engineering, Icon Therapeutics, Janssen R&D, Kala Pharmaceuticals, Kanghong, Kato Pharmaceuticals, Notal Vision, Novartis, Ohr Pharmaceuticals, Optovue, QLT, Quantel, Regeneron, RestorGenex, RetroSense, Santen, Shire, Stealth
25
FINANCIAL DISCLOSURE INFORMATION (continued)
Biotherapeutics, Thrombogenics, Valeant, Vision Medicines, Xcovery
Contracted Research: Acucela, Alcon/LPath, Allergan, Astellas, Corcept,
Genentech, Kala Pharmaceuticals, Kato Pharmaceuticals, Novartis,
Ohr Pharmaceuticals, Ophthotech, QLT, Quantel, Regeneron, Sanofi/
Genzyme, Stealth Biotherapeutics, Thrombogenics
Jacobs, Deborah:
Salary: Boston Foundation for Sight (501 (c)3
Miller, Joan
Royalty: Valeant Pharmaceuticals (licensee); Massachusetts Eye and Ear Infirmary (assignee): Royalties related to photodynamic therapy for conditions involving unwanted ocular neovascularization. Elsevier: Royalties related to textbook
Receipt of Intellectual Property Rights / Patent Holder: Valeant Pharmaceuticals (licensee); Massachusetts Eye and Ear Infirmary (assignee): Intellectual property rights related to photodynamic therapy for conditions involving unwanted ocular neovascularization ONL Therapeutics (licensee); Massachusetts Eye and Ear Infirmary (assignee): Intellectual property rights related to methods and compositions for preserving photoreceptor viability.
Consulting Fees: Alcon Research Council (advisory board), 2011-09-01 to
present Amgen, Inc., 2014-09-18 to 2015-09-18 KalVista Pharmaceuticals,
2012-03-31 go present Maculogix, Inc., 2013-10-03 to present (non-
remunerative 2013-10-03 to 2015- 05-01).
Contracted Research: Lowy Medical Research, Ltd., A natural history observation and registry study for macular telangiectasia type 2: The
Mactel Study
Noecker, Robert
Consulting Fees: Allergan, Alcon, Inotek, Aerie, Ocular Therapeutics,
Kateena, EndoOptiks, Iridex, Quantel
Contracted Research: Allergan, Glaukos, InnFocus, Aquesys
Ownership Interest: Ocular Therapeutics
Talamo, Jonathan
Consulting Fees: Abbott Medical Optics, Alcon, Wavetec Vision,
SV Life Sciences, Moelis Capital, Cowen and Company,
Surgiste Boston, LLC
Contracted Research: Abbott Medical Optics
Ownership Interest: Optimedica Corporation, Wavetec Vision,
CXL Ophthalmics
26
FINANCIAL DISCLOSURE INFORMATION (continued)
Yun, S.H. Andy
Recipient of Intellectural Property Rights/Patent Holder: Inventor of
patents of some technologies related to optical coherence tomography and
Brillouin microscopy.
NO FINANCIAL INTEREST
None of the other individuals in a position to control the content of this activity,
including planners, CME Review Committee members, faculty presenters,
moderators, panelists and reviewers have any relevant financial relationship with an
ACCME-defined commercial interest to disclose.
27
CANDIDATES PROPOSED FOR MEMBERSHIP
CANDIDATE PROPOSER
SECONDER
Alice Lorch, MD Boston, MA
Carolyn Kloek, MD
Boston, MA
Matthew Gardiner, MD
Boston, MA
Lisa Neavyn, MD Unionville, CT
Peter Zacharia, MD
Worcester, MA
Frank McCabe, MD
Worcester, MA
Amy Parminder, MD
Chestnut Hill, MA
Deborah Jacobs, MD
Needham, MA
Sergei Urman, MD
Brookline, MA
David Reed, MD
Plymouth, MA
Michael Morley, MD
W. Yarmouth, MA
Chirag Shah, MD
Boston, MA
NEOS SCIENTIFIC POSTER PROGRAM
Hecht Awards for Best Resident, Fellow, and Trainees Posters
June 3, 2016
Residents, fellows, and trainees from all the New England ophthalmologic teaching programs are invited and encouraged to submit
abstracts for a scientific poster presentation contest to be conducted
at the June 3, 2016, NEOS meeting. Posters will be judged on originality and scientific merit. Awards will be made for the first prize
$500.00, second prize $300.00, third prize $200.00 and three honorable mentions of $50.00 each. Funding for the awards is derived
from a gift to the NEOS Education Endowment Fund honoring the
late Sanford Hecht, MD. Poster presentations exhibited at ARVO
in 2016 and at the AAO meeting in of 2015 may be submitted.
We encourage all trainees to participate in this event.
To submit posters, go to:
neos-eyes.org – future meetings/June 3/abstract submission form
DEADLINE for abstract to appear in printed program is
May 15, 2016.
For questions, please contact Judy Cerone Keenan at (617) 227-6484
or [email protected].
28
FUTURE NEOS MEETINGS
2016
April 15
June 3
September 30
(Hynes Convention
Center)
December 2
(NB – New Date)
Systemic Disease
William Tsiaras, MD
Retina
(1st Miller Lecture)
Chirag Shah, MD
Ocular Trauma/Emergencies
Carolyn Kloek, MD
Subspecialty Sessions:
Posterior Uveitis/Retina Lucia Sobrin, MD
Neuro-ophthalmology Joseph Rizzo, MD
Cornea/Refractive
Peter Rapoza, MD
Neuro-ophthalmology
Sashank Prasad, MD
Ethics and Risk Management
Oren Weisberg, MD
Cataract
John Papale, MD
2017
Retina
March 3
April 21
June 2
Subspecialty Sessions:
Jennifer Sun, MD
Retina Jeffrey Moore, MD
Oculoplastics Susan Tucker, MD
Uveitis Sarkis Soukiasian
Imaging
Theresa Chen, MD
Elias Reichel, MD
Surgical Complications
Bradford Shingleton, MD
Glaucoma Controversies
James Umlas, MD
Bonnie Henderson, MD
Jeffrey Heier, MD
Joan Miller, MD
Dean Eliot, MD
29
NEOS Executive Board and Committees 2015-2016
David Lawlor, MD, President
Jeffrey Heier, MD, President-Elect
John Dagianis, Vice President
Chair Admissions Committee
Mary Daly, MD, Secretary
Joseph Levy, MD, Treasurer
Chair Finance Committee
Joel Geffin, MD,
Immediate Past President
Chair Nominating Committee
Executive Committee
David Lawlor, MD, President
Jeffrey Heier, MD,
President-Elect
Joseph Levy, MD, Treasurer
Michael Bradbury, MD,
Executive Director (ex officio)
Admissions Committee
John Dagianis, MD, Chair
Jeffrey Heier, MD
David Lawlor, MD
Finance Committee
Joseph Levy, MD, Chair
Joel Geffin, MD
Jeffrey Heier, MD
John Dagianis, MD (ex officio)
Michael Bradbury, MD
(ex officio)
Nominations Committee
Joel Geffin, MD, Chair
Ann Bajart, MD (MA)
Mitchell Gilbert, MD (CT)
Elliot Perlman, MD (RI)
Christopher Soares, MD (VT)
David Weinberg, MD (NH)
Charles Zacks, MD (ME)
ex officio members:
Drs. Bradbury, Daly, Lawlor,
Heier, Levy, Roh
30
Joan Miller, MD, Past President
Chair, Policies Committee
Shiyoung Roh, MD, Past President
Jonathan Talamo, MD, Chair, Program Committee
Michael Price, MD, Chair Educational Endownment
Fund Committee
Phil Aitken, MD, Chair, Ophthalmic Services Committee
Laura Fine, MD, Chair, Public Health & Education Cttee
Jorge Arroyo, Chair, Information Technology Committee
Michael Bradbury, MD, Executive Director
Program Committee
Jonathan Talamo, MD, Chair
Fina Barouch, MD
Jay Duker, MD
Geoffrey Emerick, MD
Gena Heidary, MD
Jeremy Kieval, MD
Carolyn Kloek, MD
Robert Noecker, MD
Lawrence Piazza, MD
David Weinberg, MD
Michael Yoon, MD
David Lawlor, MD (ex officio)
Jeffrey Heier, MD (ex officio)
Ophthalmic Services
Committee
Phil Aitken, MD, Chair
Timothy Blake, MD
Kathryn Hatch, MD
Edward Jaccoma, MD
Marc Leibole, MD
Erin Lichtenstein, MD
Cynthia Mattox, MD
Lauren Shatz,MD
Trexler Topping, MD
David Vazan, MD
John Dagianis, MD (ex officio)
Jeffrey Heier, MD, (ex officio)
Public Health and
Education Committee
Laura Fine, MD, Chair
Richard Eisenberg, MD
Macie Finkelstein, MD
Magdalena Krzystolik, MD
Joseph Levy, MD
Robert Lytle, MD
Brendan McCarthy, MD
Susannah Rowe, MD
Cathryn Welch, MD
Michael Wiedman, MD
John Dagianis, MD (ex officio)
Jeffrey Heier, MD, (ex officio)
Committee for Educational
Endowment Fund
Michael Price, MD, Chair
Caroline Baumal, MD
Thomas Coghlin, MD
Francis D’Ambrosio, MD
Richard Dornfeld, MD
Mathew Gardiner, MD
Christopher Newton, MD
David Lawlor, MD
Joseph Levy, MD
Society Policies Committee
Joan Miller, MD, Chair
Shiyoung Roh, MD
Joel Geffin, MD
Jeffrey Heier, MD
John Dagianis, MD
Michael J. Bradbury, MD
Information Technology
Committee
Jorge Arroyo, MD, Chair
Paul Greenberg, MD
Johanna Seddon, MD
Anish Shah, MD
Ankoor Siddharth Shah, MD
Elliot Perlman, MD, (emeritus)
Judith Cerone Keenan
Executive Assistant
Exhibitors (at time of printing)
Alcon - SPONSOR
817.615.2448
www.alconlabs.com
Allergan - SPONSOR
714.246.4491
www.allergan.com
AMO
413.329.3555
www.Amo.abbott.com
Bausch and Lomb - SPONSOR
949.916.9352
www.bausch.com
Carl Zeiss Meditec
925.557.4158
www.meditec.zeiss.com
Diopsys
973.244.0622
www.Diopsys.com
Ocular Therapeutix
781.357.4008
www.ocutx.com
OIC
781.341.1070
www.Oic2020.com
Prodigy Health
US Compounding Pharmacy
877.693.4376
www.prodigyhealth.com
Raskind Ophthalmic Group/Optovue
508.272.1320
www.raskindeye.com
Reichert, Inc
716.686.4518
Tissue Bank International
617.722.9900
www.tbionline.com
Eagle Vision/Rhein Medical
800.222.7584
www.eaglevis.com
Freshkote
Hoya Surgical Optics
909.680.3900
www.thehoyafreeformcompany.com
Heine USA
603.842.6621
www.heine.com
Lombart
757.855.1232
www.lombartinstruments.com
Marco
904.642.9330
www.marco.com
Microsurgical Technology
425.556.0544
www.microsurgical.com
Ocular Systems
336.784.4603
www.ocularsystemicsinc.com
31
All Donors, please pick up an EEF Ribbon at registration to wear at meetings.
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32
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and Surgeons
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33
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The Rivers School
34
In Memory of Dr. Peter Gudas:
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Dr. Lawrence Piazza
Dr. Theodore Renna
Molly-Jane Isaacson Rubinger
In honor of Trexler Topping
Dr. Domenic M. Strazzulla
Dr. Carter Tallman
Dr. Michael Wiedman
In honor of Dr. Claes Dohlman
NOTES
35
NOTES
36
758 MEETING
TH
NEOS
www.neos-eyes.org
ETHICS AND RISK
MANAGEMENT
CORNEAL ECTASIA AND
REFRACTIVE SURGERY
MARCH 11, 2016
Back Bay Event Center
180 Berkeley Street
Boston, MA 02116