- Warren Hill, MD, gives ASCRS Lindstrom Lecture
- Dr. Glaucomflecken entertains ASCRS meeting attendees
- Audience votes on best rapid-fire presentations in ‘X-Rounds’
- Symposium tackles topic of co-existing ocular disease and cataract surgery
- Pearls for improving refractive cataract surgery
Warren Hill, MD, gives ASCRS Lindstrom Lecture
This year, Warren Hill, MD, gave the Lindstrom Lecture, presenting “Accuracy for IOL Power Selection … Are We There Yet?” Cataract surgery is a growth industry, but one of the problems is it has a limited capacity, Dr. Hill said. There are about 9,750 cataract surgeons in the U.S., and there were 4.6 million cataract surgeries performed in the U.S. in 2022, with an average of 472 cases per surgeon.
By 2030, Dr. Hill predicted that cataract surgeries would reach 6 million per year. Additionally, the older than age 65 population will increase by 30.5%, and the mean patient age for cataract surgery will decrease. He estimated that there would be 10,000 ophthalmologists doing cataract surgery in 2030, with each surgeon handling around 600 cases per year.
So, how can we be more efficient? Dr. Hill said avoiding complications is the overall goal. Unanticipated refractive outcome is the most common complication of routine cataract surgery. He then went on to discuss IOL power selection, noting that anterior segment surgeons are being judged by patients and peers by refractive outcomes.
In terms of accuracy standards, Dr. Hill questioned whether what’s most common should be good enough. He then talked about the history of IOL power calculation methods, as well as current options. A significant part of the accuracy of modern theoretical formulas depends on the correct estimation of the effective lens position before surgery, he said.
Is there another way we can do this? Dr. Hill added that this might be a case for the development and use of artificial intelligence. Artificial intelligence-based models are being developed for the diagnosis, classification, and management of ARMD, ROP and pediatric cataract, retinal vein occlusion, diabetic retinopathy, glaucoma detection and management, keratoconus detection and progression prediction, refractive surgery suitability, and IOL power selection.
AI does not limit possibilities to situations that are already understood, Dr. Hill said. It’s able to make the best of what’s available, bypassing the limitations of physical models. It’s also well-suited to real-world problems where ideal models are not available.
We have sophisticated validation tools that allow for insights into calculation accuracy before surgery, he said. This has incredible sensitivity for identifying and unraveling complex, non-linear relationships, and it’s free of calculation bias.
He also discussed pattern recognition with AI. So why shouldn’t this be used for IOL power? Artificial intelligence allows for the use of a tool that anticipates the accuracy of the calculation. He also mentioned some new tools to predict postoperative accuracy, including a boundary model. He showed his open-access online Hill-RBF calculator, which can help predict correct IOL power. He noted that there are ongoing updates to the Hill-RBF calculator.
Ophthalmology is experiencing a convergence of technologies for IOL power selection accuracy, Dr. Hill said, noting ray tracing, advanced vergence formulas, artificial intelligence, and intraoperative aberrometry. The method with greatest sensitivity and flexibility will give the greatest accuracy as technology advances, he said, adding that 80% right now is passable; 85% is acceptable; and 90% is achievable. We’re not quite there yet, but with exciting new tools, we’re getting closer, he said.
Editors’ note: Dr. Hill has financial interests with Haag-Streit.
Dr. Glaucomflecken entertains ASCRS meeting attendees
William Flanary, MD—better known as Dr. Glaucomflecken—shared a bit of comedy during the Sunday General Session.
He kicked off by talking about advice he’d offer trainees and younger ophthalmologists. When you come to a conference, you’re going to hear famous ophthalmologists talk about things they do, and it’s going to give you imposter syndrome, he said. “If you feel like you don’t belong or you’re not good enough, just remember no one at this conference knows how to use a stethoscope,” he joked.
Dr. Flanary mentioned one of his early interactions with Warren Hill, MD, who he met for the first time when he was a resident. He said that he should have asked for Dr. Hill’s advice, but instead, Dr. Flanary asked Dr. Hill to write down his favorite IOL formula and sign it.
Dr. Flanary stressed how important it is to incorporate humor into daily life. He started doing comedy at 17 years old and even showed an old photo of a comedy club he used to perform at.
While Dr. Flanary decided to pursue a career in medicine rather than comedy, he continued to do comedy on the side. “What I started realizing was that humor and medicine are a perfect match for each other,” he said.
Dr. Flanary took a break from comedy when he was diagnosed with testicular cancer in his third year of medical school. He recovered physically, but he noted the emotional toll this took on him, and he got back into comedy to deal with it.
“When we’re faced with something in life … something unforeseen, we feel like control over our own lives is taken away from us,” he said. Humor helps you take that thing and rearrange it and present it the way you want. It helps you reassert control over that situation, he said.
Dr. Flanary finished medical school and moved on to residency. But in his third year of residency, he was diagnosed with testicular cancer again. This time, he turned to social media to share his humor after a friend suggested that he get on Twitter.
Dr. Flanary had to decide what to call himself, and he joked that it was between Dr. Glaucomflecken and Dr. Pseudophacodonesis. “People actually think Dr. Glaucomflecken is my real name,” he said, saying that sometimes patients call his office asking to make an appointment with Dr. Glaucomflecken.
Dr. Flanary tried out his social media humor at the Association for Research in Vision and Ophthalmology (ARVO) meeting, sharing an early tweet of his that only had 5 likes and 3 retweets. “The more you do something, the better you’ll get,” he said. Dr. Flanary realized the power of social media for those in healthcare. He noted how it can help with advocacy, education, networking, and self-expression.
It can be helpful, he said, to bring humor into advocacy. What we do to patients as a healthcare system is criminal regarding insurance, he said. “I’ve done a lot of content based around health insurance to show people the issues we have,” he said, sharing a video he did humorizing the prior authorization issue with Aetna and why the insurance company would have chosen to do that.
Dr. Flanary also discussed using social media as a form of self expression. There’s this idea that you can’t show who you are as a doctor because it sacrifices professionalism, he said, but that needs to go away. “I want my doctor to seem like a real person,” he said. We have to maintain a level of professionalism, but it shouldn’t come at expensive of showing who we are, he said.
Following his presentation, Dr. Flanary sat down for a Q&A with Edward Holland, MD, and Dagny Zhu, MD.
Dr. Zhu discussed how she got into social media, noting that it’s amazing how professional organizations have embraced social media in medicine. She emphasized why doctors should care about social media. If doctors are not meeting patients where they are online, patients will be encountering pseudo-experts who often promote false and often dangerous information, she said. It’s a public health duty for doctors to have a presence on social media, she said.
Dr. Zhu likes to focus on education, networking, advocacy about issues important to her, and providing mentorship and inspiration to the next generation. You can decide what your strengths are and decide what matters to you and what you want to get out of the platform, she said.
Dr. Flanary also encouraged those on social media to keep posting. It can be discouraging when you put content out there and don’t get response, he said, but if you keep posting, you’ll find your audience.
Dr. Zhu added that one key is to be authentic, and she added that sharing personal experiences is often a great way to engage others.
Editors’ note: The speakers have no financial interests related to their presentations.
Audience votes on best rapid-fire presentations in ‘X-Rounds’
X-Rounds: Refractive Cataract Surgery to the Max is a fast-paced symposium where members of the panel presented their answer to a question or thoughts on a topic in 2.5 minutes or less. The audience voted for their favorite in each section. Eric Donnenfeld, MD, moderated this session Sunday afternoon and was joined by Kerry Solomon, MD, John Hovanesian, MD, Elizabeth Yeu, MD, Edward Holland, MD, and Nicole Fram, MD, on the panel.
Here are the winners from each category:
What am I doing differently this year?
Winner: Nicole Fram, MD
Dr. Fram said her focus is on ergonomics, or what she called “heads up, chest out.” Fifteen percent of ophthalmologists have some neck pain or back issues, Dr. Fram said. She said her practice investigated the different types of heads-up displays, finding that there are pros and cons to both. The winning technology, Dr. Fram said, is going to be the one with data integration and also the smallest footprint.
New technology on the horizon
Winner: Edward Holland, MD
Dr. Holland said he’s most excited about new corneal endothelial cell therapy being worked on by Aurion Biotech where cells from a healthy donor are cultured to make millions of new donor cells. The diseased endothelium of a patient is brushed off, and then the healthy cells are injected, followed by the patient lying face down for 4 hours.
Pearl for the management of astigmatism
Winner: Kerry Solomon
Dr. Solomon said that that a paper by Steve Schallhorn, MD, and co-authors looked at more than 34,000 eyes and their postop astigmatism and uncorrected DCVA. He said we were always taught to leave patients a little myopic. The data from Schallhorn et al. suggested that we should leave them a little hyperopic, Dr. Solomon said. He presented that if the intention is to leave the patient emmetropic, it is better to err on the side of hyperopia than myopia for multifocal or monofocal IOLs. The research also showed that leaving a little with-the-rule astigmatism was correlated with increased patient satisfaction.
Favorite surgical or pharmacologic treatment of presbyopia
Winner: John Hovanesian, MD
Dr. Hovanesian spoke about UN 844 (lipoic acid/choline ester 1.5%, Novartis), which he said is a presbyopia-mitigating drop under investigation that “works differently.” Its mechanism of action is not shrinking the pupil, Dr. Hovanesian said. This drug is metabolized to lipoic acid and choline that breaks the disulfide bonds that limit lens flexibility, giving it some of the presbyopia accommodation it had before.
Best surgical save of the year
Winner: Edward Holland, MD
Dr. Holland shared a case where a professional European football player suffered severe ocular injury after a firework explosion. His partner Jeffrey Nerad, MD, rebuilt the patient’s upper and lower lid, and a few months later, Dr. Holland said he did an ocular surface stem cell transplant. One of the patient’s siblings was an identical match with conjunctiva and limbus harvested from her eye. Dr. Holland said he performed the “Cincinnati Procedure,” which used deceased donor tissue from 3:00–9:00 and the conjunctival and limbal stem cells from his sister to restore the patient’s ocular surface. Once this procedure was proven successful, Dr. Holland performed a PK. After total recovery, the patient had 20/40 vision in his worse eye and was back to playing football.
Editors’ note: The speakers have financial interests with various ophthalmic companies.
Symposium tackles topic of co-existing ocular disease and cataract surgery
Presentations in the Cataract Crossover symposium covered different scenarios when co-existing ocular disease poses a challenge to cataract surgery. These can include oculoplastic disease, retinal disease, glaucoma, neuro-ophthalmic disease, and corneal disease. The session covered preoperative, intraoperative, and postoperative risks and considerations for cataract surgery in these complex eyes.
“This is one of the first years we’re doing this symposium,” said Zaina Al-Mohtaseb, MD, one of the session’s co-moderators. “We silo ourselves in our different subspecialties … but I think with cataract surgery, especially the increasing patient expectations, it’s important to know, if it does pertain to cataract surgery, the other subspecialties.”
Wendy Lee, MD, spoke about cataract surgery in patients with oculoplastic disease. She highlighted different oculoplastic conditions that cataract surgeons might encounter, like lower lid ectropion and lid retraction. The typical thyroid patient, for example, has upper and lower lid retraction, Dr. Lee said, explaining that they are candidates for blepharotomy. She questioned whether the cataract surgery should be done before or after. While it’s not a hard and fast rule, Dr. Lee’s general rule is to leave about 4 months between the procedures, whichever comes first. Are there refractive changes after a lid procedure? Dr. Lee shared a paper that found refraction, astigmatism, and HOAs are generally unchanged by lid surgery.
For ptosis, Dr. Lee said to make sure it’s not a tumor causing the ptosis; palpate the lacrimal gland area. If it is true ptosis, do the cataract surgery first, she said. Taking care of the ptosis first could create exposure of the cornea, which could affect healing. Dr. Lee recommended lagophthalmos surgery before cataract surgery.
“When you book patients for cataract surgery … flip that upper lid and see what’s underneath,” Dr. Lee said, adding, “you want to make sure there are no cysts, scar tissue, or tumors.” She also said to make sure you have a clear drainage system, free from infection, before surgery. If you have a patient who needs a Jones tube, she said cataract surgery should be done before its placement. If the patient already has a Jones tube, Dr. Lee said to make sure the patient takes precautions to not blow their nose in the immediate postop period and use antibiotics and other measures to clean the ocular surface.
Nathan Radcliffe, MD, said his presentation is “not just another MIGS talk,” rather it is about cataract surgery in patients who have glaucoma. These eyes are not normal, he said. Every part of the eye is affected by glaucoma and glaucoma treatments and need to be considered when evaluating for cataract surgery.
Dr. Radcliffe said he is liberal with acetazolamide if there is ever a question. He said he’ll put 20–30% of his patients on a couple of doses on the day of surgery, “because it’s so much better than running into trouble.” He also said that patients with glaucoma are more likely to miss refractive targets (mostly due to surface disease), but this should be in the preop conversation, especially for premium patients.
Editors’ note: Dr. Lee does not have financial interests related to her comments. Dr. Radcliffe has financial interests with various ophthalmic companies.
Pearls for improving refractive cataract surgery
The “Essential Strategies for Improving Refractive Cataract Surgery Outcomes” symposium, moderated by Kevin M. Miller, MD, and Warren Hill, MD, covered pearls to enhance refractive outcomes, such as explaining what refractive cataract surgery is, advanced IOL power calculations, astigmatism management, and premium IOL implantation.
Richard Tipperman, MD, shared his five pearls for explaining refractive cataract surgery to patients.
- Word choice makes a difference/simpler is better. Dr. Tipperman said how you describe a monofocal IOL will make a difference in the patient’s unconscious perception of lens choice. Most patients will not remember or understand “monofocal IOL,” but he cautioned against using terms like “standard,” “routine,” or “conventional,” which could bias them to thinking this is the lens everyone picks. The better term, Dr. Tipperman said, is “basic.”
- Avoid the “premium.” The word “premium” implies paying a higher price for something that is a luxury purchase that doesn’t make a difference in function. Dr. Tipperman said “advanced technology” is his preferred term.
- Set the “expectations bar” low. Dr. Tipperman said to describe basic lenses as giving excellent distance vision but everything from arm’s length inward will not be clearly visible without glasses. Talking about multifocal as better than basic, he said, will hit the mark every time.
- Show the cockpit. Dr. Tipperman said showing patients topography, the biometry calculations, etc., helps them understand their situation and the complexity of the care they’re receiving. It drives home the value of the procedure and the knowledge base required, he said.
- Review the potential for glare/halo. Dr. Tipperman noted that things discussed before surgery are “expectations,” while those discussed after are often perceived as “complications.” Discuss the potential for glare/halo with advanced-technology IOLs as rare but treatable. He also said it’s helpful to use pictures.
Helga Sandoval, MD, shared five pearls for IOL calculations. “To me, calculations for IOLs are like an art. It’s not one size fits all. Every patient is different, and they want different things,” she said.
- Ocular surface optimization. This is not just preoperatively, Dr. Sandoval said, but intraoperatively and postoperatively, as needed.
- Use validation criteria. Dr. Sandoval highlighted validation guidelines for IOLMaster (Carl Zeiss Meditec) and Lenstar (Haag-Streit) measurements proposed by Dr. Hill. She also said to make sure the axis is correct, comparing the map to measurements, and compare multiple measurements before proceeding.
- Use modern formulas. Dr. Sandoval listed the Barrett Universal II, Hill RBF V3.0, Kane, and Ladas, but she said that you have to find what works for you. She said that many of these formulas are available online, and you need to make sure that any data entered is correct.
- Constant optimization based on your postop data.
- Use cataract surgery planning software. Dr. Sandoval said these systems avoid manual data entry and ease of formula comparison, but she said this is a tool. “This isn’t going to tell you what to do. … You still have to think what will be best for your patients.”
Editors’ note: Dr. Tipperman has financial interest with Alcon. Dr. Sandoval does not have financial interests related to her comments.
See the June 2022 issue of EyeWorld for more follow-up of sessions at the 2022 ASCRS Annual Meeting.
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