Meeting Reporter
Reporting Live from The Royal Hawaiian Eye
on the Big Island

Question patients on Flomax histories

Commencing bimanual MICS
in a Flomax (Boehringer
Ingelheim GmbH, Germany)
patient with a well-dilated pupil.
Source: David F. Chang, M.D.

It’s imperative that surgeons question male cataract patients to ascertain if they are taking or have taken Flomax (Boehringer Ingelheim GmbH, Germany), a systemic alpha-1 antagonist medication, said David F. Chang, M.D., University of California, San Francisco.
Even patients that discontinued use of the drug two years prior to cataract surgery experienced Intra-operative Floppy Iris Syndrome (IFIS). Indicators of IFIS include billowing of the iris, prolapse, and miosis. Stretching and sphincterotomies are ineffective for IFIS, Dr. Chang said.
In studies of more than 1,600 patients, 95% of the 2% to 4% of patients with IFIS had a history of Flomax use. Flomax is the most commonly prescribed medication for benign prostatic hypotrophy.

Editors’ notes: Dr. Chang has no financial interests related to his comments.

Dr. Chang is scheduled to speak on this topic at next month’s ASCRS•ASOA Symposium & Congress, Washington, D.C. For more information, call 703-591-2220.


Power modulation, regulation key to avoiding wound burns

Randall J. Olson,
M.D.

Power modulation and regulation are critical to avoid wound burns during microphaco surgery, said Randall J. Olson, M.D., director, John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City.
Research conducted by Dr. Olson and colleagues has centered on in vitro measurements specifically with the Sovereign (Advanced Medical Optics, AMO, Santa Ana, Calif.) and Legacy with Advantec (Alcon, Fort Worth, Texas) phaco equipment.
Researchers determined rapid attainment of temperatures that potentially cause wound burns are nearly impossible to achieve without occlusion or near occlusion.
In addition, researchers concluded the Sovereign power control acts like a gas pedal controlling the amount of energy to the phaco tip.
In comparison, the Legacy acts like a cruise control determining the amount of stroke length.
The result: The Legacy will increase or decrease power depending on the hardness of the nucleus while the Sovereign will increase or decrease the stroke length with the same power depending on the work load (hardness of the nucleus), if both pedals are consistently held at the same point. Therefore, the WhiteStar (AMO) micropulsing technology results in no detectable wound heating in clinical conditions.
Researchers also determined techniques greatly affect chances of wound burn and concluded vertical chop offers the least risk.
Dr. Olson and colleagues recently completed a survey on the incidence of wound burns in association with specific features of the machines. The correlation of the study findings with those of the in vitro study were extremely close and thus allowed researchers to conclude that in vitro principles are critical in how burns are created, Dr. Olson said.
The in vitro study consisted of controlled runs that measured the temperature on the phaco sleeve inside of an artificial anterior chamber. It looked at continuous, pulsed, and ultra-pulsed phaco energy both occluded and unoccluded, as well as with varying amounts of weight added to increase friction.

Editors’ note: Dr. Olson is a consultant for AMO but has no financial interests in their products.

Debate continues over “blue blocker” lenses

The AcrySof Natural IOL
(Alcon, Fort Worth, Texas)

In a spirited discussion about the blue blocker lens (AcrySof Natural, Alcon, Fort Worth, Texas), Jack T. Holladay, M.D., Baylor College of Medicine, Houston, said no studies in peer-review journals show a connection between blue light exposure and the development of AMD.
In fact, blue light blocker lenses severely compromise contrast sensitivity and reduce night vision, he said.
Counterpoint: James P. McCulley, M.D., University of Texas Southwestern Medical School, Dallas, and Robert J. Cionni, M.D., medical director, Cincinnati Eye Institute, Ohio, both maintained “science and logic,” as Dr. McCulley said, plus in vitro studies published in the peer-review literature (Chesapeake Bay Study), show blue light is toxic to the eye.
That information, combined with studies that show that blue blocker lenses do not compromise visual acuity, make the arguments of Dr. Holladay a ‘dead issue,’ Dr. Cionni said. “I see what patients tell me and I know they can tell the difference, between dark blue and black,” Dr. Cionni said.
He went on to state that theoretic arguments claiming potential problems with color vision and night vision caused by blue blocker lenses are flawed and counterintuitive. Extensive clinical results demonstrate no negative impact on visual function caused by blue blocker lenses, Dr. Cionni said.

Editors’ note: Drs. Cionni and McCulley are consultants for Alcon. Dr. Holladay has financial interests in Pfizer (New York) and Advanced Medical Optics (AMO, Santa Ana, Calif.).

Pre-loaded injectors improve safety

Improved safety is available to cataract patients in the form of pre-loaded injectors, said Stephen Bylsma, M.D., University of California at Los Angeles, Santa Maria, Calif.
Dr. Bylsma outlined the IOL injectors produced by several companies, including Advanced Medical Optics (Santa Ana, Calif.), Alcon (Fort Worth, Texas), and Bausch & Lomb (Rochester, N.Y.). Injector technology needs to overcome damage to IOLs including tearing the optic; avulsing haptics; plunger over-ride; uncontrollable delivery, reproducible delivery, and minimizing incision size.
The future of injection technology includes preloaded IOLs, he said. Such devices will include advantages including simplicity, efficiency, and reproducible sterility.
The numerous technical challenges include: many IOLs cannot be stored folded; some IOLs cannot be stored in the cartridge; and various packaging and shelf-life issues.

Editors’ note: Dr. Bylsma is a consultant for STAAR Surgical (Monrovia, Calif.), an injector manufacturer.


Swab striae away

A Q-Tip swab cotton swab can help eradicate striae under a LASIK flap, said Eric D. Donnenfeld, M.D., Ophthalmic Consultants of Long Island and co-chairman of Cornea and External Disease at Manhattan Eye, Ear and Throat Hospital.
The technique Dr. Donnenfeld uses involves: Opening the flap 180 degrees; leaving the hinge and inferior flap in place; and then pressing the cotton swab firmly to push striae toward the periphery. The technique allows easy removal of striae at the slit lamp without returning to surgery.

Editors’ note: Dr. Donnenfeld has no proprietary interests related to his comments.

Pearls to banish microstriae

Although macrostriae are unlikely to improve with time and require surgical attention, epithelial remodeling may lead to improved quality of vision for those with microstriae, said Stephen D. McLeod, M.D., vice chairman, Department of Ophthalmology, University of California, San Francisco.
Dr. McLeod suggested the following techniques for evaluation and quantification: Quality of best spectacle corrected visual acuity; retinoscopy; wavefront (although this can be misleading due to tear film irregularity); and using fluorescein to examine the tear break-up pattern.
A simple refloat with repositioning is a reasonable first step to resolve striae concerns, but surgeons must take care to avoid over-hydration, Dr. McLeod said.
Other pearls and remarks he provided regarding the simple refloat include: The necessity to re-establish good flap position; the shift of alignment marks when working with a displaced flap; and the need to use the symmetry of gutters as an indicator of good flap position.

Editors’ note: Dr. McLeod has no proprietary interests related to his comments.


Pearl for glaucoma patients

Before performing refractive surgery on a glaucoma patient, stop all topical medications for two weeks or the medications will significantly delay healing, said Eric D. Donnenfeld, M.D. Surgeons should use oral agents to control pressure instead of topical medications, he said.

Editors’ note: Dr. Donnenfeld has no proprietary interests related to his remarks.

Richard L.
Lindstrom, M.D.

Stephen G.
Slade, M.D.

Marguerite B.
McDonald, M.D.

Large pupils don’t negate refractive surgery

Although legal literature suggests large pupil size is a risk factor during refractive surgery, medical literature does not agree.
During a panel discussion on refractive surgery complications, Richard L. Lindstrom, M.D., adjunct professor emeritus, University of Minnesota, Minneapolis, said he performs surgery on any pupil size.
Stephen G. Slade, M.D., Houston, agreed and added that no simple nomogram shows this shouldn’t be done. Surgeons should instead consider pre-op symptoms and the amount of myopia with which patients present.
In the past, ablations were not well centered, which risked complications in those with large pupils, said Marguerite B. McDonald, M.D., clinical professor of ophthalmology, Tulane University School of Medicine, New Orleans. Modern technology has made centration a non-issue, Dr. McDonald said.

Editors’ note: Drs. Lindstrom, Slade, and McDonald have no financial interests related to their remarks.

Practitioners: Treat cause, not symptoms, of dry eye

Patients using Restasis (Allergan, Irvine Calif.) often discontinue use of artificial tears to soothe their dry eyes, said Edward J. Holland, M.D., director, cornea service, Cincinnati Eye Institute, Ohio.
Dr. Holland prescribes Restasis because it is very safe and does not cause toxicity of the epithelium. Dr. Holland also recommended surgeons put dry eye patients on diets rich in omega 3 fatty acids, which decrease ocular inflammation.
In a separate discussion, John R. Wittpen, M.D., associate clinical professor of ophthalmology, State University of New York at Stony Brook, recommended surgeons prescribe Restasis for allergy sufferers.
Pearl: Prescribe four daily doses instead of the usual two and formulate it up to 0.5%. Consider requesting tears or oil formulations, Dr. Wittpenn said.
In a third presentation, Eric D. Donnenfeld, M.D., associate professor of ophthalmology, New York University, said activated T-cells may disrupt lacrimal glands and cause ocular surface tissue damage.
Restasis inhibits T-cell activation, he said. In a real world, open label study conduced with chronic dry eye patients, Restasis b.i.d. was prescribed for 14,927 patients. More than 70% of dry eye patients surveyed about the onset of action and satisfaction of treatment reported their symptoms were relieved.
John D. Sheppard, M.D., associate professor of ophthalmology, microbiology and immunology, Eastern Virginia Medical School, Norfolk, Va., is scheduled to present a study at next month’s ASCRS•ASOA Symposium & Congress, Washington D.C., that found corticosteroids decreased the irritation associated with Restasis use by 75%, Dr. Donnenfeld said.

Editors’ note: Dr. Holland is a consultant for Bausch & Lomb (Rochester, N.Y.). Drs. Wittpenn and Donnenfeld are consultants for Allergan. Dr. Sheppard is on Allergan’s and Santen’s (Napa, Calif.) advisory boards; performs clinical research for Allergan and Alcon (Fort Worth, Texas); and he is a speaker for Alcon, Allergan, and Santen.

For more information on the upcoming ASCRS•ASOA Symposium & Congress, check www.ascrs.org or call 703-591-2220.


Lid hygiene recommended for blepharitis treatment

Henry D. Perry,
M.D.

The first step to manage blepharitis is to ensure proper lid hygiene, although such care is not guaranteed to resolve the problem, said Henry D. Perry, M.D., cornea and external disease specialist, Rockville Centre, N.Y.
The best way to conduct lid hygiene is to use cotton balls suffused with warm salt water.
In a study of 36 patients with meibomian gland dysfunction, treated with lid hygiene and artificial tears, 88% reported improvement, although no discernible signs of change were noted, Dr. Perry said.

Editors’ note: Dr. Perry reported no proprietary interest in his remarks.