- Phaco essentials covers everything from iris repair to surgeon ergonomics
- ‘Cornea Corner’
- Glaucoma Treatments in 2022
- ‘Best of ASCRS’
Phaco essentials covers everything from iris repair to surgeon ergonomics
Daniel Chang, MD, kicked off the ASCRS Summer Meeting, saying that it is meant to give a “taste of the Annual Meeting—we get a little bit of everything but in a more personal setting.” The first session, Phaco/Cataract Essentials, went through iris and zonular issues, dense cataract cases, compromised cornea, and ergonomics for cataract surgeons.
Mitchell Weikert, MD, described different approaches that he takes for iris problems. One is the 4-throw pupilloplasty, which was originally pioneered by Amar Agarwal, MD. Dr. Weikert said this is a “super easy way to fix an iris defect.” He said that with this technique you have two paracenteses on either side of the defect. A suture is passed through either side and you “fish out” a loop (Dr. Weikert said he used a J-hook to do this). From there, you wind around one side of the loop four times, internalize the knot, and tighten. From a third paracentesis, you cut the suture.
Dr. Weikert also described pupillary sculpting using cautery to help achieve a centered, round pupil, a technique for repairing iridodialysis, and iris cerclage.
Cathleen McCabe, MD, took on the topic of loose or missing zonules. The first step, she said, is to look for clues of this ahead of time to ensure you can be prepared for the case. These clues include a history of trauma, pupil size, pseudoexfoliation material, movement of the lens, iris transillumination defects, depth of the anterior chamber, and the space between the iris and anterior capsule. Dr. McCabe said zonular issues can be observed on UBM.
In cases of mild zonulopathy, Dr. McCabe likes to use preloaded CTRs, while in moderate cases you might need capsule hooks or a segment, she said. For moderate to severe zonulopathy, Dr. McCabe presented a case that used a pupil expander for capsular support, a CTR, and Ahmed segments. In another case, she put in a capsular tension segment at the beginning of the case, using it as a support system to keep the loose lens up from the beginning. A final technique she described was using a CTR in the bag with an IOL placed in the sulcus with optic capture.
Other pearls that Dr. McCabe offered for these cases were to have a backup plan (backup lenses calculated, sulcus power conversion chart on hand, etc.), have acetylcholine available, and practice several suturing techniques beforehand.
Beeran Meghpara, MD, discussed “chalky,” white cataracts, which he said implies intumescent cataracts where the contents are under pressure. The most difficult part with these cases, Dr. Meghpara said, is in creating the capsulorhexis because it is at risk of running out into the Argentinian flag sign.
With these cases, start small with the capsulorhexis, gradually making it bigger, as its their tendency to naturally run out. Take your time and perform gentle hydrodissection, Dr. Meghpara said, noting a few other techniques to begin the capsulorhexis in these cases as well.
“Whatever technique you use, keep pressure up in the anterior chamber and decompress capsular contents,” he said.
The femtosecond laser can be used in the case of white lenses, but Dr. Meghpara cautioned that liquified material can quickly come forward, block the laser, and inhibit complete creation of the capsulorhexis. Be on the lookout for tags in these cases. He also mentioned Zepto (Centricity Vision) for automatic capsulorhexis creation and said that it makes complete contact with the capsule and a capsulorhexis within 4 milliseconds.
Zaina Al-Mohtaseb, MD, shared her thoughts on cataract surgery when there is a compromised cornea. These corneas can affect your IOL calculation accuracy, cataract surgery can worsen preexisting corneal disease, and visual outcomes can be limited, she said. It’s important to do a topography on patients prior to cataract surgery to identify corneal irregularities that might be missed in the clinic. Dr. Al-Mohtaseb shared several corneal conditions that could impact cataract surgery and how she handles them either before or after the cataract procedure.
Finally, Inder Paul Singh, MD, spoke on a topic that affects cataract surgeons themselves: ergonomics. Dr. Singh said that he never had symptoms of the spinal injuries caused by long days hunching toward a pair of oculars until he fell off a ladder changing a light bulb and experienced brief paralysis. After this incident, Dr. Singh learned that this occurred because he had spinal stenosis. He underwent surgery to put a plate in his neck.
“Ergonomics is so important,” he said. “You may not have any symptoms for decades, but it catches up with you.”
Dr. Singh said surgeons need to bring chairs closer to the table and raise the table height. Foot positioning with pedals during surgery can make a difference as well. In the clinic at the slit lamp, similar principles apply in terms of bringing the chair closer to the table, raising the slit lamp, and angling the oculars so that the physician’s neck can remain upright.
Dr. Singh said he now performs most of his procedures using a heads-up microscope, where he looks at a 3D screen rather than into oculars.
“No matter how hard we try to be good, keeping good posture during surgery, … it is really hard. Heads-up surgery really helped me, allowed me to sit back,” he said.
Dr. Singh also advocated for physicians to perform the “chin tuck exercise,” which he said takes 30 seconds, every 2–3 hours.
Editors’ note: The physicians have financial interests with various ophthalmic companies.
‘Cornea Corner’
During the cornea section of the Saturday program, presentations covered diagnostics, dry eye masqueraders, OSD treatments, OSD procedures, corneal transplants, and keratoconus and crosslinking.
Jennifer Loh, MD, shared information on dry eye diagnostics during her presentation. Diagnosing is never as simple as it should be, she said. Patients can have symptoms but no signs. They could also have full tear lake and still be symptomatic. You can have perfect cataract surgery and the patient see may great but could complain of dry eye for months after.
There are many symptom questionnaires available, Dr. Loh said, mentioning the OSDI, SPEED, and SPEED 2 questionnaires. She also mentioned the signs and many ways to test for dry eye, including vital dyes, tear breakup time, tear lake volume, meibomian gland health, and presence of scurf/collarettes on the upper lids and lashes.
When posing several questions to panelists and attendees, she mentioned that it’s recommended to wait 3 minutes to grade fluorescein corneal staining to allow for maximum corneal staining. She also mentioned that lissamine green dye is used specifically to grade the conjunctiva, and based on a study, 55% of patients seen in a typical eye doctor’s office have collarettes.
Before wrapping up, Dr. Loh also shared some of the other tests that can show that a patient has dry eye, including corneal topography, meibography, and objective non-invasive tear testing (like MMP-9 and tear osmolarity).
Also during the session, Kourtney Houser, MD, discussed options for managing ocular surface disease. She said one of the first things to do is to try to figure out the mechanism of the disease, either aqueous deficient dry eye or evaporative dry eye. Many patients have a combination of the two, she said.
To treat aqueous deficient dry eye, Dr. Houser recommended using artificial tears. Try to stay away from preservatives, she added. Additionally, Dr. Houser said that punctal occlusion can be helpful. She suggested possibly starting with collagen plugs but also noted that silicone plugs may last longer.
For patients with evaporative dry eye, Dr. Houser said treatment may include doxycycline, thermal pulsation, IPL, and tea tree oil.
If these initial options don’t work, Dr. Houser said that anti-inflammatories are the next step. There are many studies showing that steroids are helpful, she said, but you don’t always like to leave patients on them long term.
Additional therapies may include autologous serum or plasma rich in growth factors (PRGF), amniotic membrane (Dr. Houser uses this option often in preoperative optimization of the surface), and scleral contact lenses.
During his presentation on keratoconus and crosslinking, William Trattler, MD, mentioned that keratoconus is progressive, so the highest risk is for younger patients, eye rubbers, and those with more advanced keratoconus. However, he noted that patients of any age can progress, and he added that 2–3% of patients who have undergone epi-off crosslinking do progress.
Dr. Trattler also discussed the value of using topography to evaluate for progression of keratoconus. One issue, he said, is that keratoconus is often discovered late. Slit lamp signs are only visible in moderate to severe keratoconus, and significant keratoconus can develop prior to significant vision loss, he said, adding that patients may still have good vision despite obviously visible keratoconus on topography. He shared topographies of several patients with keratoconus who still had 20/20 vision. So, if you’re not doing topography, you may miss it, he said.
Dr. Trattler also mentioned genetic testing that can help determine the risk of a patient developing keratoconus, noting that there is no single gene that has been identified as the direct cause of keratoconus.
He added that annual visits with topography are important for all keratoconus patients.
Editors’ note: The physicians have financial interests with various ophthalmic companies.
Glaucoma Treatments in 2022
The glaucoma section on Saturday’s program focused on glaucoma treatments in 2022. “We have the opportunity in glaucoma to get patients off medications,” Inder Paul Singh, MD, said. This helps with many things, including compliance and quality of life, he said. With the options available in glaucoma today, Dr. Singh said you don’t have to choose between quality of life and controlling IOP, and you don’t have to choose between compliance and safety. It’s not just IOP reduction that defines success in glaucoma, he said, adding that reduction in the number of medications and less chair time for physicians and their staff are also important factors in addition to IOP reduction.
Dr. Singh also mentioned that using multiple glaucoma medications may increase the risk of dry eye. The more you add, the more risk, he said, and this can also reduce the chance that patients will be compliant with medications. Dr. Singh said that he’s noticed that some glaucoma doctors have commented that they don’t have time to look at dry eye but noted that he uses a Wratten filter to help with this.
Also during his presentation, Dr. Singh mentioned “redefining controlled glaucoma,” noting that while this includes IOP, visual field, and optic nerve stability, it also includes quality of life. We have a role as educators for everyone to feel comfortable doing MIGS, he said. When polling the room, Dr. Singh was excited at the number of cataract surgeons who indicated that they were doing MIGS, adding that there has been an uptick in the last several years. He also provided a brief breakdown of the conventional outflow MIGS, noting outflow stents, dilation of the outflow systems, and TM stripping/removal.
Manjool Shah, MD, discussed some exciting upcoming options in the pipeline for glaucoma 2022 and beyond. He first noted that it has now been a decade since the iStent (Glaukos) was approved. Before that, all we had were trabs and tubes, he said. “The next 10 years are going to be remarkable,” Dr. Shah said.
First, Dr. Shah highlighted some options in sustained release, all currently in investigational stages: the Glaukos iDose TR, PolyActiva Latanoprost, and the Ocular Therapeutix OTX-TIC.
He added that it will be exciting in the future, with this platform created, to have the option to introduce additional agents after starting with prostaglandin analogs.
Dr. Shah then went on to discuss new surgical options, highlighting four new products.
First was the XEN63 (Allergan), which Dr. Shah said has a similar mechanism of action as the currently available XEN45, but with 1.4x wider lumen. All other things are essentially equal, with an almost 4x reduction in outflow resistance compared to XEN45, he said. The insertion technique and injector are similar, so you just get a “little more bang for your buck,” he said.
The Santen PRESERFLO has a 70-micron lumen diameter and is 8.5 mm in length. One novel aspect, Dr. Shah said, is the SIBS material, which is inert, biocompatible, and less tissue reactive. Early data shows tremendous promise, he said, with pressures in the low teens.
The iSTAR MINIject is another new option, which targets the supraciliary space. It features porous silicone composed of hollow interconnected spheres to allow for flow regulation and avoid fibrosis. It allows a slow, controlled outflow and a little space for tissue ingrowth that doesn’t completely shut it down, Dr. Shah said.
Lastly, he mentioned the MicroOptx Beacon, which has direct flow from the anterior chamber to the ocular surface. It also has material properties and nanoscale fabrication to prevent protein deposition or bacterial entry.
Editors’ note: The physicians have financial interests with various ophthalmic companies.
‘Best of ASCRS’
During a Saturday afternoon session, “Best of ASCRS: What the faculty learned this year,” panelists shared some of their favorite papers from the ASCRS Annual Meeting. Marjan Farid, MD, moderated the panel, with David Crandall, MD, Jennifer Loh, MD, William Trattler, MD, and Mitchell Weikert, MD.
One of the papers that Dr. Farid shared focused on the recently approved IC-8 (AcuFocus), which utilizes the pinhole optic effect. The study sought to assess the effectiveness of a non-toric small aperture IOL in cataract patients with preoperative corneal astigmatism up to 1.5 D. It found that the IC-8 IOL delivered consistent visual performance at distance, intermediate, and near for patients with up to 1.5 D of preoperative corneal astigmatism without the need for a toric lens. Eyes with less than 1.0 D of preoperative astigmatism and eyes with 1.0–1.5 D of preoperative astigmatism achieved equivalent UCDVA, UCIVA, and UCNVA.
Commenting on this new technology, Douglas Koch, MD, said he participated in the clinical trial for this lens, and noted that treating irregular astigmatism has been a “sweet spot” for this lens. With this aperture, you can bring people with irregular astigmatism almost up to level of normal eye, he said. “I think it’s going to be a nice addition to what we can offer for patients.”
Dr. Crandall shared glaucoma papers, with one particularly focusing on MicroPulse (Iridex), a non-invasive option in glaucoma surgery. He noted that he is using this option a lot earlier in the treatment process and said that he has even used it for some patients who were 20/20. If you’re trying to avoid incisional surgery, Dr. Crandall said this option could potentially work well in patients with low pressure.
Dr. Loh shared some of her chosen refractive papers, with one focusing on vitrectomy improving contrast sensitivity function in multifocal pseudophakia.
With age, the vitreous becomes less clear, she said. The vitrectomy study used limited vitrectomy in patients with monofocal and multifocal IOLs and in phakic eyes. It found that contrast sensitivity function improved in all groups (37% improvement in the multifocal group, 48% in the monofocal group, and 41% in the phakic group). The study stressed that limited vitrectomy helped reduce echodensity and improved contrast sensitivity in all eyes, and limited vitrectomy is a safe and effective cure for vision degrading myodesopsia in multifocal pseudophakia.
Dr. Trattler presented cornea papers, sharing a next generation crosslinking calculator for patients with thin corneas. The crosslinking study concluded that crosslinking could be performed in corneas thinner than 420 microns, while still respecting safety restrictions. This can help delay the need for a transplant in thin corneas. The NXT calculator is free to download. But the study also noted that long-term follow up is needed, as well as a larger patient cohort.
Also presenting on cataract papers, Dr. Weikert shared a paper on performance of the Eyhance (Johnson & Johnson Vision) lens. The Eyhance lens was compared to the monofocal ZCB00 lens (Johnson & Johnson Vision) in a large number of eyes. The study found that patient-reported satisfaction was high for both IOLs. Additionally, it found that objective and subjective distance performance of the Eyhance was comparable to the monofocal IOL. The Eyhance had better UCIVA and UCNVA within the first year, while the ZCB00 monofocal was better at the 20/16 or better level.
Editors’ note: The physicians have financial interests with various ophthalmic companies.
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