- Roberto Zaldivar, MD, delivers the Steinert Lecture
- Richard Lindstrom, MD, gives Obstbaum Lecture
- Video cases offer a ‘Reay of Hope’ at Glaucoma Day
- Cornea Day covers topics in keratoconus, corneal ectasia, lamellar surgery
Roberto Zaldivar, MD, delivers the Steinert Lecture
The Steinert Lecture, named in honor of the late Roger Steinert, MD, is a main feature of ASCRS Refractive Day. Since it was first established in 2017, this lecture has been given by an ophthalmologist who has made significant contributions to refractive surgery.
This year, Roberto Zaldivar, MD, delivered the lecture, showcasing his 35-year journey in refractive surgery and sharing how defying standards helped him to create and be involved in the evolution of different techniques and designs.
Vance Thompson, MD, who introduced Dr. Zaldivar and the lecture, described Dr. Zaldivar as an innovator and great teacher who has been highly sought after. Dr. Zaldivar performed the first ICL surgery in the world in 1993 and spent the decades since refining the surgery and the implant. He said that, like Dr. Steinert, Dr. Zaldivar is an extraordinary individual. His family has a legacy in ophthalmology, with his father being an ophthalmologist and his son, Roger Zaldivar, MD, as well.
Dr. Zaldivar, leading into his lecture, said it was “a real honor to be a recipient of this distinguished recognition.” He said that Dr. Steinert and he worked in the same building when he was a fellow in Boston, and that Dr. Steinert was his inspiration. “To take this recognition in his name is really a privilege,” Dr. Zaldivar said.
To date, he has performed more than 200,000 refractive procedures and 23,000 phakic IOL procedures. In 1991, refractive surgeries included RK, keratomileusis, lensectomy, and a few others. When he was invited to Russia at the time, he saw a phakic lens procedure and said he was convinced it was the path forward.
In September 1993, he put in the first ICL in Mendoza, Argentina. Soon afterward with infrared photos, they started to observe decentration and rotational issues with the ICL. So Dr. Zaldivar said he met with the team at STAAR Surgical and helped design the current “footplates” that help avoid rotation and decentration.
After this, another problem presented itself. Lenses were getting broken with the injector, which at that time had a metal tip and was designed for silicone IOLs. This problem was solved with the development of an injector with a foam tip. Another problem was pupillary block. Dr. Zaldivar said they began doing two iridotomies to combat this and later developed the implant to have a central hole (avoiding the need for iridotomies) in 1994. Dr. Zaldivar showed a picture with a patient 20 years after the first procedure with the version that had the central hole. The 73-year-old patient didn’t have a cataract and had excellent vision, which Dr. Zaldivar said amazed the team. A couple of years after designing the central hole, they started to suspect that it could be producing a dysphotopic effect, but they didn’t know for sure.
In 1996, Dr. Zaldivar coined the term Biotics to describe a combined laser and ICL procedure. Then, he described the end of the 1990s as the “darkest hours.” Complications that hadn’t occurred before began to appear, such as anterior capsular opacity.
Around this time, in 1999, Dr. Zaldivar saw a patient for a 3-year ICL follow-up. The patient had a cataract in one eye but nothing in the other. The difference was one eye had vault under the ICL, the other didn’t. “We needed vault to avoid cataracts,” Dr. Zaldivar said, describing how the posterior curvature of the lens was then improved. But even this wasn’t perfect because some anatomical differences between eyes didn’t allow for consistent vault.
In 2011 came the “aquaflow revolution,” Dr. Zaldivar said, with a design that forced aqueous humor over the crystalline lens, through the pinhole in the middle, and into the angle. Out of 7,214 of this design implanted with between 1 month and 10 years of follow-up, there has been no cataract, no pupillary block, and no pigmentary dispersion, he said. He called the Aquaport “a great step forward.”
In terms of patient acceptance, Dr. Zaldivar said 90% of patients would rate their experience as 10 out of 10. Compared to LASIK, those with an ICL were more likely to say they were “extremely satisfied” (100% compared to 84.6%).
Dr. Zaldivar said there are new tools to further enhance the procedure and outcomes: software to predict vault, high-resolution ultrasound to show the real position of the lens,
and intraoperative OCT to avoid overcorrection.
“In my opinion, the appearance of this new lens model in the USA is going to be the most disruptive technique in refractive surgery in the coming years,” Dr. Zaldivar said.
Editors’ note: Dr. Zaldivar has no financial interests related to his comments.
Richard Lindstrom, MD, gives Obstbaum Lecture
Richard Lindstrom, MD, delivered the 2022 Stephen A. Obstbaum, MD, Honored Lecture, at Glaucoma Day, focusing on cataract surgery, MIGS, and refractive cataract surgery for glaucoma patients.
Nathan Radcliffe, MD, introducing Dr. Lindstrom, said he has more than 45 patents, 75 fellows, is the author of more than 400 papers, and is the namesake for the ASCRS Richard L. Lindstrom, MD, Lecture and Medal, among other accomplishments.
Cataract surgery itself is a “modern miracle,” Dr. Lindstrom said, restoring vision to 295 million patients globally in the past 25 years. But 20.5% of these patients, 74 million, were on medications for ocular hypertension or glaucoma. In and of itself, cataract surgery can improve intraocular pressure.
“One could argue that cataract surgery alone is the most common glaucoma surgery performed today. Is cataract surgery a glaucoma surgery? I think the evidence supports this fact,” Dr. Lindstrom said.
Dr. Lindstrom cited a paper by Poley et al. published in the Journal of Cataract & Refractive Surgery in May 2008 that found that “IOP reduction after cataract surgery is significant, sustained, and proportional to the preoperative intraocular pressure.” But why does cataract surgery alone reduce eye pressure?
“It was our thought that the elevated pressure was phacomorphic, that the natural lens had an impact, as it grew and expanded in size, on the facility of outflow and elevated pressure,” Dr. Lindstrom said. “It’s clear that we don’t have this definitively known but … we think the mechanical theory is supportable and logical.”
Cataract extraction may alter the tone of the trabecular meshwork beams, resulting in improved outflow, Dr. Lindstrom noted in the presentation. He said that advances in cataract surgery have allowed us to separate cataract surgery and more invasive glaucoma surgery. He explained that physicians used to do a lot of phaco-trab procedures, but the thought arose that we can just do cataract surgery in these milder cases and only do more invasive surgery later if we’re not successful.
Further, MIGS changed the world of glaucoma. A study he presented on the largest iStent (Glaukos) dataset found that the effect of one first-generation iStent to cataract surgery is sustained and additive. At baseline, participants had an average IOP of 19 mm Hg on 1.4 meds. After cataract surgery plus iStent, IOP dropped 4 mm Hg. While there was an initial decrease in medications by 50%, medication use slowly increased, which could be due to the progressive nature of the disease and because the number of people available for follow-up got smaller.
A comparative study of cataract surgery plus Hydrus (Ivantis/Alcon) vs. cataract surgery alone showed that more patients (65%) were medication- free in the Hydrus group compared to cataract surgery alone (41%) after 48 months. The mean IOP unmedicated was 16.7 mm Hg in the Hydrus group compared to 17.2 mm Hg for cataract surgery alone.
Dr. Lindstrom also discussed the safety profile of many MIGS plus cataract surgery procedures as being similar to that of cataract surgery alone.
MIGS and canal-based glaucoma procedures dominate today’s glaucoma surgeries, Dr. Lindstrom said. He noted that glaucoma procedures have doubled in the last decade, but trabeculectomy and tube shunt procedures have only grown 12% within that.
“The growth in glaucoma surgery is definitely in the minimally invasive category,” he said. “But, and there’s a but, MIGS is still only offered by 46% of U.S. surgeons, and as many as 38% say they’re … not going to ever do it. We’ve got too many eye surgeons who have no plans to offer MIGS.” Dr. Lindstrom said while glaucoma specialists have readily adopted MIGS, he thinks comprehensive ophthalmologists could do a better job.
Dr. Lindstrom then spoke about refractive cataract surgery for patients with glaucoma. This can include astigmatic correction and presbyopia correction.
Dr. Lindstrom called refractive cataract surgery a win for patients and families, providing the potential for improved quality of life and functionality. For ophthalmologists, refractive cataract surgery improves the surgeon’s knowledge and skills, provides more patients with access and choice, and offers additional revenue, Dr. Lindstrom said.
There are special considerations for refractive cataract surgery when the patient has glaucoma. According to their clinical trials, PanOptix (Alcon), a trifocal, and Vivity (Alcon), an extended depth of focus (EDOF) IOL, have no to low reduction in contrast sensitivity. For patients who have ocular hypertension or mild glaucoma, Dr. Lindstrom said he would consider an EDOF or trifocal lens, but he would not implant these in patients with moderate to severe disease.
In terms of astigmatism, he said he thinks all these patients should have this correction offered, regardless of glaucoma severity. Options include corneal relaxing incisions or toric monofocal, toric accommodating IOLs, or the Light Adjustable Lens (RxSight).
In his final thoughts, Dr. Lindstrom said he thinks that all patients with ocular hypertension or mild to moderate glaucoma on medications deserve to be offered a MIGS option at the time of cataract surgery. He said that we’re failing our patients a little bit there. He added that patients should at least be informed of the opportunity and, in his experience, after informing them, almost everyone says yes.
He also said that refractive cataract surgery, with proper IOL selection and patient counseling, is an option for these patients, depending on glaucoma severity.
“Cataract surgery, MIGS, and refractive cataract surgery are a win-win. They are good for patients and good for ophthalmic surgeons,” he said.
Editors’ note: Dr. Lindstrom has financial interests with various ophthalmic companies.
Video cases offer a ‘Reay of Hope’ at Glaucoma Day
The 12th Annual Complications and “Reay of Hope” Video Session during Glaucoma Day featured several complicated video case presentations. The session was moderated by Manjool Shah, MD.
Poonam Misra, MD, presented “Search and Rescue,” a case by Joseph Panarelli, MD. In this case, an exposed Ahmed valve (New World Medical) needed to be removed and replaced with a Baerveldt (Johnson & Johnson Vision). Dr. Panarelli took out the plate and tube but when attempting to remove the capsule ended up cutting a rectus muscle. Dr. Misra asked, what’s next? Dr. Panarelli decided to find and rescue the muscle, sewing it with Vicryl and a weaving technique with locking passes on either end of the muscle.
“One thing I tell our residents every time is to hook the muscles, hook the muscles, and hook them again, because you really want to know where they are,” Dr. Misra said. She also said it’s important to isolate the muscle to separate any Tenon’s and capsule so that the muscle is not overly tense.
This was a recent case, Dr. Misra said, so they don’t have a full outcome to report yet.
Kuldev Singh, MD, presented a case involving an 18-year-old patient with ROP with laser treatment at birth, cataract surgery in both eyes, 20/400 vision, and terrible nystagmus. He was on five medications and acetazolamide with a pressure of 13 mm Hg. Dr. Singh said this patient needed single-digit pressures.
He was planning a limbus-based trab but found in the OR that a trab attempt had been made there before, so he pivoted and ended up doing a tunnel to the clear cornea. He made a flap and noted how the conjunctiva was “just tacked down,” meriting more dissection to create a bigger bleb. He used 0.4 mg of MMC on a sponge for 5 minutes.
“Now the question is, is this going to work? It will depend on what happens in the next couple weeks,” Dr. Singh said, adding later that he’s got a good feeling about it based on the first weeks postop.
Nathan Radcliffe, MD, took the audience on a “wild ride.” His case involved a patient who presented with an IOP of 60 mm Hg, exfoliation glaucoma, and a small pupil. Preop visual acuity was hand motion only. He said you might wonder why do surgery if the patient was hand motion only, but the patient was on “all drops” and likely would end up with a decompensated cornea and pain. Thus, he leaned toward intervention.
Things were going well with the cataract procedure, but there was a bit of an anesthesia issue, he thinks due the patient’s pressure being 60. He did a little pars plana vitrectomy to make more space, then the patient started moving. When he was later cleaning up a little bit of cortex, he noticed that the red reflex looked only half red.
“What am I looking at? I seem to have a limited choroidal hemorrhage,” he said.
Would you still place an Ahmed valve? His IOL was in the bag, the Malyugin ring was taken out, and things were looking reasonably well when the IOL spontaneously dislocated in the bag. “The plan at this point is leave this chamber with viscoelastic in it, use [acetazolamide], MicroPulse [Iridex], and prayer, and see how we can go,” he said.
Postoperatively, Dr. Radcliffe said the patient was “not that bad,” with pressure in the 30s (a 50% reduction, he said to some laughs).
“This eye retained vision, the pressure was controlled, and the patient was not in pain,” Dr. Radcliffe said.
Ema Avdagic, MD, showed a case of persistent anterior chamber shallowing after PRESERFLO MicroShunt (Santen). At postop day 1, the patient’s anterior chamber was moderately deep. By postop week 1, her anterior chamber was flat and she had an IOP of 7 mm Hg. Dr. Avdagic performed a PROVISC fill (sodium hyaluronate, Alcon). Between postop week 2–4, the patient’s IOP was less than 10 mm Hg. A PROVISC fill was performed at week 2, and SF 6 fill at week 3.5. VISCOAT (chondroitin sulfate, Alcon) fill, GSL, and needle IZHV were performed at postop week 4. At this point the anterior chamber was now moderately deep but choroidals persisted. By postop week 6, there were “kissing choroidals.”
From here, Dr. Avdagic said choroidal drainage (with scleral windows), IZHV, and GSL were performed. At postop month 1 the patient had an IOP of 11 mm Hg on no medications, the PRESERFLO bleb looks good, the anterior chamber is deep, and the choroidal effusions resolved.
After seeing each of the presentations, the audience voted for Dr. Radcliffe’s case.
Editors’ note: Drs. Misra and Avdagic have no financial interests related to their comments. Drs. Singh and Radcliffe has financial interests with various ophthalmic companies.
Cornea Day covers topics in keratoconus, corneal ectasia, lamellar surgery
The first session of the 2022 Cornea Day program covered updates in the management of keratoconus and corneal ectasia. During the session, Sumit “Sam” Garg, MD, presented on genetics, specifically genetic testing and applications in keratoconus. We know that keratoconus is a bilateral progressive corneal ectasia resulting in irregular astigmatism and loss of visual function, with onset in teenage years, Dr. Garg said. Diagnosis is generally made by a corneal specialist, by looking at patient history and symptoms, as well as clinical signs, corneal topography/tomography, and pachymetry mapping. Now, genetic testing is beginning to be used for keratoconus.
Keratoconus prevalence is individual, and there is not a “one size fits all” approach. Dr. Garg mentioned that optical coherence tomography (OCT), wavefront aberrometry, and corneal biomechanics tests are newer exams that may be used for diagnosing keratoconus.
He then spoke about the use of genetic testing for diagnosis of keratoconus. The AvaGen (Avellino) 75-gene panel plus more than 2,300 variants identifies the risk of most keratoconus and 70-variant gene TGFBI corneal dystrophy patients. The test has been validated in more than 1,100 patient DNA samples in the U.S.; patient samples are displayed with a risk score reference bar, from 0 to 100, using a green-yellow-red scale. Each patient sample receives its own numeric risk score and determination of low to high risk.
Who should you consider getting a genetic test on? Dr. Garg mentioned several groups of patients who might benefit: those with topography/tomography anomalies (astigmatism pattern concerns, pachymetry, posterior corneal bowing), those with unstable refractions (differentiating early myopia from keratoconus), where there are concerns of post-LASIK ectasia, those with ocular allergy/eye rubbing, at-risk family members of known keratoconus patients, and those with high association with keratoconus (Down syndrome, Marfan syndrome).
Dr. Garg shared a few cases where he used genetic testing. The first was a 32-year-old female who had been referred after LASIK evaluation, with no recent refractive changes, and she denied eye rubbing. The patient also denied family history of keratoconus and was motivated to have LASIK. The genetic test showed moderate to high risk, so Dr. Garg decided not to use laser and to follow up at 6 months with the patient. He also said he would potentially consider crosslinking for this patient.
His second case was a 31-year-old female who had been seen elsewhere for a LASIK evaluation, and the doctor recommended PRK. The patient had no recent refractive changes and denied eye rubbing. When looking at the maps, Dr. Garg noted that nothing looked abnormal. The results of the genetic test were not particularly helpful in this case; it noted a moderate keratoconus risk.
Lastly, he shared the case of a 27-year-old prior contact lens user with stable refraction. The maps showed a bit of thinning but a good residual stromal bed. Dr. Garg is currently seeing this patient and has not yet performed the genetic test, but he questioned panelists if their opinion of this patient would change knowing that the patient’s father had keratoconus.
In conclusion, Dr. Garg said that genetic testing for keratoconus is new and holds a lot of promise. It allows risk stratification, aids with clinical quandaries, and hopefully helps with early diagnosis and screening. Dr. Garg stressed that the test results are not binary, but rather they are a spectrum. He said to expect evolving guidelines of how best to incorporate genetic testing for laser vision.
The second session of Cornea Day focused on anterior/posterior lamellar surgery. Winston Chamberlain, MD, PhD, discussed what really matters when requesting donor tissue. He first discussed factors that surgeons care about when asking for donor tissue, noting that he asked his local eye bank about some of the factors. Minimum endothelial cell density, age, death to preservation, death to surgery, and medical rule-outs were some of the factors. The eye bank said that 88% of active domestic surgeons have at least one tissue parameter.
Later in his presentation, Dr. Chamberlain discussed myths relating to donor tissue.
The first was that younger grafts are better for PKP and DSAEK. Donor age is not an important factor in most penetrating keratoplasties for endothelial disease, he said, noting data from the Cornea Donor Study. Five-year graft survivals for corneal transplants at moderate risk for failure are similar using corneal tissue from donors older or equal to 66 years compared to donors younger than 66.
The second myth was that cell counts matter for PKP and DSAEK. The Cornea Donor Study, Dr. Chamberlain said, showed that preoperative endothelial cell density is unrelated to graft failure from endothelial decompensation. There was strong correlation of endothelial cell density at 6 months with graft failure from endothelial decompensation. A graft can remain clear after 5 years even when the endothelial cell density is below 500 cells/mm2, he said.
Dr. Chamberlain also noted that for DSAEK, certain donor factors were not associated with greater endothelial cell loss at 3 years after surgery in the Cornea Preservation Time Study, including cause of death, time from death to preservation, lenticule thickness, eye bank-dissected versus surgeon-dissected donor lenticule tissue, donor sex, and donor age.
The third myth Dr. Chamberlain addressed was that shorter preservation time (death to surgery) is safer. Longer preservation time was associated with greater endothelial cell loss at 3 years after DSAEK surgery, although much of the effect was attributed to the very longest preservation times, which were from 12–14 days. He added that less than 12% of all U.S. PKP, DSAEK, and DMEK tissue transplanted in 2020 had death to surgery time longer than 8 days.
Dr. Chamberlain also addressed the myth that being pickier about tissue is “just being a good surgeon.” But he said that “our picky parameters” have effects on cost and tissue supply. This can increase the cost of donor tissue and limit the donor pool.
The last myth he addressed is needing better parameters because physicians think they are not as good a surgeon as others. The studies we have generalize with all of us, he said. They include multiple centers and multiple surgeons who contributed to data collection with their own cases.
What about DMEK? Dr. Chamberlain said that DMEK levels are very similar to DSAEK now, and using older grafts may be the choice for surgeons on the learning curve. He added that there are more studies and data to come relating to DMEK, and he noted both the Diabetes Endothelial Keratoplasty Study (DEKS) and the Descemet Endothelial Thickness Comparison Trial (DETECT).
Editors’ note: Dr. Chamberlain has financial interests with a variety of ophthalmic companies. Dr. Garg has financial interests with Avellino and Glaukos.
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