- Innovator’s lecture covers improving patient care through innovation and tracking outcomes
- Engaging ‘Refractive Bachelor(ette)’ back for another season
- ASOA speaker tells attendees about ‘life in the espresso lane’
- ‘International Superheroes’ share their problem-solving skills
- Surgical monovision
Innovator’s lecture covers improving patient care through innovation and tracking outcomes
Francis Price Jr., MD, delivered the 2022 Charles D. Kelman, MD, Innovator’s Lecture during Monday’s Innovators General Session.
Dr. Price spoke about improving patient care through innovation and tracking outcomes. He said that ASCRS is really an association of innovators, founded to promote ideas and technologies that, while commonplace now, were initially controversial, such as phacoemulsification, IOLs, and refractive surgery. Innovators are not necessarily inventors, like Dr. Kelman, Dr. Price said, adding that not all innovations work. As innovators, he continued, we should share our ideas with others and strive to improve care and outcomes for our patients.
There needs to be a balance between innovation and regulation, Dr. Price said. Regulation can serve to protect patients, but it also can increase costs, be a barrier to entry, and delay development. Innovation can improve treatment outcomes, tailor treatments to patients, and disrupt the status quo. But, he said, unregulated or untracked innovations can lead to the “wild west.” The wild west can be controlled, if we’re responsible and we track our results, Dr. Price said, adding that when we’re not responsible, the result can be more regulation.
He then went on to describe some of his early work, including the creation of the Cornea Research Foundation of America (CRFA) in 1988. The goal was to have a database for corneal transplants (prior there was no tracking of grafts in the U.S) with fulltime researchers and the ability to conduct studies. At the time CRFA was founded, Dr. Price said nonprofit regulations were different. Study regulations were also looser: retrospective studies didn’t require IRB approval, “off-label use” was not an issue,” and there were little to no regulations for devices that were small volume and not marketed, he said.
The work of CRFA allowed tracking and analyzing of corneal transplants, offering the ability to see the advantages of DSEK in 2003 and DMEK in 2008. The databases also enabled them to demonstrate the differences to PK for both patients, physicians, and at times insurance companies, Dr. Price said.
Dr. Price also described a multicenter study that compared LASIK and contact lens wearers (the first study to track LASIK for 3 years and to compare LASIK to a control group). It found that LASIK outperformed contacts in terms of night driving, patient satisfaction, dry eye, and infections/abrasions.
Research and techniques from the CRFA helped change corneal transplants, providing the first prospective, randomized studies on topical steroid dosing after corneal transplants, a prospective study on stopping steroids after 1 year for DMEK, and it identified glaucoma tubes as the most significant risk factor for EK failure, Dr. Price said. He questioned whether large databases, which are commonplace now, will replace single-center databases. He thinks not because while large databases have the advantage of seeing what’s going on all over, single centers have more consistent data entry, highly skilled and experienced surgeons, potentially better follow-up, and may be better at determining cause and effect.
Dr. Price said the next data challenge is healthcare reform. He spoke about how the data can be used to show the effect of taking “physicians out of the equation,” the effect of pharmaceutical costs, and how preventative care and lifestyle modifications can improve health.
Editors’ note: Dr. Price has no financial interests related to his comments.
Engaging ‘Refractive Bachelor(ette)’ back for another season
The ‘Refractive Bachelor(ette)’ was back for Season 2 at ASCRS, offering education on refractive cataract surgery options in an engaging, lively, and often humorous format.
Host David F. Chang, MD, said there are more refractive IOL options to offer cataract patients than ever before. As such, it has become much harder to see which IOL or which strategy they should choose to be happy for the rest of their life, he continued. This session had “bachelors” and “bachelorettes” present different patient scenarios followed by surgeons sharing what they think the best lens would be for the patient.
Audrey Talley Rostov, MD, was the first bachelorette, posing as a 58-year-old interior designer who had a history of LASIK, dry eyes, and large pupils. She thinks her LASIK has “worn off,” and she is experiencing glare at night. She’d like to see her computer better without glasses or contacts and maintain her activities, which include hiking, standup paddle boarding, open water swimming, and bird watching. She is –1.75 + 0.5 x95 OD and –2.5 + 1.00 x 110 OS, 1–2 NS, and has a normal macular OCT.
Her first candidate was an EDOF lens offered by Robert Weinstock, MD. Dr. Weinstock said his lens can achieve all the things Dr. Rostov wants for her vision. He said he doesn’t want her to worry about her LASIK because there is technology to account for that and, he added, they can do another LASIK or PRK if she needs a tune-up postop. He told her about the Symfony (Johnson & Johnson Vision) IOL and Vivity (Alcon), recommending Vivity with a little mini-monovision to achieve her desired spectacle independence.
Dr. Rostov’s next candidate was the Light Adjustable Lens (RxSight) presented by Neda Shamie, MD. She said that for a patient who is so precise and wants the best vision without glasses, it’s hard to get to that without the possibility of a lens that can be adjusted after it has been implanted. Dr. Shamie said there is room for lens power calculation errors, especially in eyes post-LASIK. Her goal is to match the best lens for the patient’s visual needs, and when combatting inaccurate corneal power calculations, the Light Adjustable Lens can be the answer. She said that she’ll get close enough during surgery and then, postop, she’ll adjust the lens to truly meet her patient’s needs. Dr. Shamie added that 97% of post-refractive eyes who have received this lens are within 0.5 D of target.
Finally, Roger Zaldivar, MD, presented the final candidate: the IC-8 (AcuFocus) small-aperture IOL. While he said Dr. Rostov would have to travel outside the U.S. (something she seemed fine with) to receive the lens, because it’s not yet available in the U.S., he thinks this could extend her depth of focus while giving her the best visual quality. The IC-8 does very well in aberrated corneas and, he added, this lens can tolerate up to 1 D of deviation from intended refractive target without appreciable change. It’s a very forgiving lens.
While the “TV audience” voted for the EDOF IOL option for Dr. Rostov, she ultimately chose Dr. Shamie’s Light Adjustable Lens.
Editors’ note: The speakers have financial interests with various ophthalmic companies.
ASOA speaker tells attendees about ‘life in the espresso lane’
Laurie Guest, CSP, CPAE, gave the keynote at the ASOA Monday General Session. Her presentation was called “Life in the Espresso Lane: How to be Smooth, Bold, and Balanced in a Fast-paced World.”
Ms. Guest, a former administrator, started in ophthalmology in 1986. She began as a receptionist at a cataract specialty practice. She joked that when she interviewed for the job, she didn’t even know what a cataract was, and when she asked her mom, she told her it was a “tumor of the eye.” She moved from receptionist to technician to surgical counselor before finally joining the administrative team.
Ms. Guest described her analogy of seeing life as a three-lane highway. When I started, I was in the far-right lane, the scenic route, the slow drip, she said, saying that she just had to show up to work on time and treat the patients right. The rest of the day was my own to do what I wanted, she said.
Working with a number of other women who had “moved to the middle ‘latte’ lane” and were getting married and having babies motivated Ms. Guest to do the same. She shared that she and her husband are celebrating 31 years of marriage this year.
Somehow that middle lane slid to the left “espresso lane,” where your days go by so fast you don’t even know where your time went, she said.
In her presentation, Ms. Guest shared a number of behaviors to change life personally and professionally. One thing she highlighted was the “praise formula,” which she described as using a person’s name followed by what they’ve done that’s praiseworthy (the more specific the better) and why it makes a difference.
Another important thing she talked about was to “forsake the mistake.” Make other people’s mistakes easy to correct, she said. There are some big mistakes that are hard to correct, and you can crisis manage those, she said, but the majority of mistakes that we or staff blow up into something big are for entertainment value. “Let’s not make mistakes a show,” she said. “Let’s fix them quietly behind the scenes.” You have to be a leader that others can bring mistakes to, she said.
Ms. Guest shared a personal anecdote about the how she used to sell sweetcorn as a child and how she “became an entrepreneur at age 5.” Her father told her three things to do to make the stand successful.
First – when every customer pulls up, look them in the eye, smile, and thank them for coming. Second – think about what your customer needs from you and do it differently from everyone else (in Ms. Guest’s case, she would give customers 13 ears of corn when they asked for a dozen and would walk the bag directly to the customer). Third – use a splash of creativity or innovation (in Ms. Guest’s case, she would get grocery bags from the store the night before and color the side of the bag, so each customer had “an original piece of art”).
Ms. Guest said that one important thing to embrace is to respond to a variety of situations with four easy words – “I’d be happy to.” When I entered the practice, there was always someone better than me, but not when it came to this, she said. “When someone asked me to do something, I would say, “I’d be happy to.’” She joked that just caused more work to come her way, but she added that having this type of attitude can make someone invaluable, especially if there is downsizing.
When staff started with us, we taught them the one lesson they had to do for their entire career with us in order to stay – we call it show time, go time, all the time, she said. When the lights go on at the practice, it’s showtime, Ms. Guest said. We hired the best people and taught them how to be great, she said.
One of the last things that Ms. Guest emphasized was to ask for what you want. She suggested that it’s better to find an opportunity to sit down with someone when something is on your mind or bothering you rather than acting out. Put some words to it, she said.
‘International Superheroes’ share their problem-solving skills
Robert Osher, MD, moderated “Surgical Problem Solving by a Faculty of International Superheroes” on Monday afternoon. This session, he said, has a faculty of key opinion leaders, innovators, and visionaries.
One of these “superheroes” was Ronald Yeoh, MD, who shared the case of a 60-year-old myope with cataract and Terrien’s marginal degeneration. He said it’s important to avoid making incisions in areas where the cornea was thinned.
“I thought, why don’t we try to do a single-handed phaco in this case,” he said, noting that the challenge of single-handed phaco is nuclear disassembly, injecting the IOL without a sideport, and rotation without a sideport and second instrument to guide it.
He found an area on the temporal side for the incision and proceeded to direct prechop, which he said is an underutilized technique. After prechopping and removing the first segment, you can breathe, because space is our friend, Dr. Yeoh said. He said you could use FLACS in these cases to fragment the nucleus, but he said that sometimes the fragments don’t separate completely, which can make removal a challenge.
Next, he injected the lens and then used a toric manipulator through the main incision, leaving it 10 degrees from its intended axis. When you take out OVD, he said, often the lens will move a little. After OVD removal in this case, he used the tip I/A handpiece upside down to engage the haptic-optic juncture and rotate 10 degrees to the final axis.
Abhay Vasavada, MD, took on the topic of cataract surgery and silicone oil, specifically when a posterior continuous curvilinear capsulorhexis (PCCC) is needed. Silicone oil, he said, often results in posterior capsule plaques.
He showed one case where after cataract surgery, a retina colleague removed the oil. From there, the cataract surgeon sutured the incision, creating a closed chamber with no leak. The cataract surgeon, he said, then performed vitreorhexis with a high cut rate and low vacuum, but the vacuum in this case was too high and there was an extension of the posterior capsule. The lens was already in the bag. The surgeon tried to bring the lens up to fixate the haptics in the ciliary sulcus, but it ended up subluxating completely. The retina surgeon brought the lens back up, and the cataract surgeon fully removed the lens, putting in a separate IOL.
He showed another case that required a PCCC due to a plaque caused by silicone oil. After the oil was removed, Dr. Vasavada said he did a manual posterior capsulorhexis, taking his time and changing ergonomics, using the incision and sideports to tear in a controlled fashion.
Dr. Vasavada’s take-home points are that PCCC is preferred over capsulectomy, you should remove the silicone oil prior to PCCC (because the oil pressure can be unpredictable), implant IOLs after PCCC, and have a backup plan to put a 3-piece IOL in the sulcus.
Editors’ note: Dr. Yeoh has financial interests with Alcon, Johnson & Johnson Vision, and Carl Zeiss Meditec. Dr. Vasavada has financial interests with Alcon.
Surgical monovision
A symposium on Monday afternoon, sponsored by the ASCRS Cataract Clinical Committee, covered “Surgical and Pharmacological Approaches to Presbyopia Management.”
Richard Hoffman, MD, presented on surgical monovision. We all are aware of the drawbacks of premium IOLs, he said. With multifocal IOLs, you could have dysphotopsias, poor neuroadaptation, poor quality of vision, and reduced contrast sensitivity. With EDOF IOLs, patients may see dysphotopsias, and in select patients, the near vision isn’t acceptable, so you have to aim for mini-monovision.
Monovision, Dr. Hoffman said, provides emmetropia in the dominant eye and myopia in the non-dominant eye. Dr. Hoffman also shared some advantages that pseudophakic monovision has over multifocal IOLs, including limited dysphotopsias, it’s not as sensitive to astigmatism and PCO, it can be utilized with corneal and macular pathology, and faster neuroadaptation.
When considering patient selection, he said you want a patient who has a strong desire for spectacle independence and someone able to comprehend monovision. The ideal candidate is also a previous monovision contact lens wearer, he said. Those with strong ocular dominance may not be good candidates, he added.
Pseudophakic monovision has a high success rate, Dr. Hoffman said. He noted a study from Greenbaum in the Journal of Cataract & Refractive Surgery that found 92% of patients were 20/30 and J1 unaided. He also pointed to data from Finkelman and colleagues in the JCRS that found, when the myopic target was -1.0 to -1.50, 96% were 20/30 or better. Additionally, a study by Marquess and colleagues found, when the myopic target was -2.0, 100% were 20/40 and J3.
How much anisometropia is ideal? What do we aim for in non-dominant eye? The current recommendation is aim for -1.0 to -1.5 D in the non-dominant eye, Dr. Hoffman said.
Does it matter what lens we use? Dr. Hoffman shared information on both aspheric and spherical IOLs. As we get older, negative spherical aberration of the lens turns into positive spherical aberration, he said. Spherical aberration can result in blurry vision and glare at night. But it may help increase depth of field, he added.
Dr. Hoffman suggested placing an aspheric IOL in the distance eye and a positive spherical aberrated IOL in the near eye.
What about astigmatism? Dr. Hoffman noted that against-the-rule (ATR) astigmatism in the far eye benefits uncorrected near acuity. The opposite may be true if the eye is left nearsighted, he said, adding that with-the-rule (WTR) astigmatism may aid near acuity in myopic eyes.
Another approach, he said, is to use an aspheric IOL with negative spherical aberration in the distance eye and fully correct astigmatism and a spherical IOL in the near eye, leaving the patient with WTR astigmatism.
Editors’ note: Dr. Hoffman has no relevant financial interests.
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