- ‘Safely Navigating More Than Just a Cataract’
- Cornea, glaucoma, and retina
- Best of ASCRS: What the Faculty Learned This Year
‘Safely Navigating More Than Just a Cataract’
During the first session on Saturday at the ASCRS Summer Meeting, presenters discussed “cataract surgery plus,” or navigating more than just a cataract. Cathleen McCabe, MD, shared a case of a traumatic cataract, which she said can present a real challenge. Her patient was hit in the left eye with a set of keys and was seeing poorly. She also had a cataract in her right eye.
Dr. McCabe said it’s important to start with a thorough history and slit lamp exam. It’s also important to know when the problem occurred, the mechanism of action, and if the lens is tilted/decentered, etc. She said to see if there is a foreign body present. A stellate pattern is typical of blunt trauma. Looking at the angle is also important to see if there’s angle recession or PAS. It’s also good to know if the patient has had prior surgery.
Dr. McCabe said imaging can be very helpful. She mentioned looking at the macula and the value of OCT. Have a plan for anesthesia to ensure you’re choosing what’s appropriate for the patient. She likes to use the femtosecond laser in these cases because there’s less traction in the eye and less movement of the lens.
Kamran Riaz, MD, discussed “the bumpy cornea patient,” noting several common issues that physicians may see frequently, including ABMD, Salzmann’s nodules, and pterygium. He also discussed previous RK and how this may impact the cornea.
He offered pearls for ABMD, noting that it’s often hiding under the upper eyelid, so it’s important to check for this. You must distinguish this from shearing injuries that can also cause recurrent corneal erosions. Look at the other eye, he said. If there is no pathology in the other eye, it’s unlikely to be ABMD.
Janice Law, MD, highlighted the ERM patient, sharing a case of a 62-year-old patient with 5 months of blurred vision and glare. Dr. Law mentioned that ERM is usually age-related over 50, and it is often triggered by PVD. However, there are also secondary causes of ERM, including many inflammatory causes.
Dr. Law said it’s important to talk to the patient about visual complaints in order to determine if the ERM is playing a role in visual complaints. Cataract and ERMs can cause blurred vision, glare, and trouble driving at night. But Dr. Law said to tease out aniseikonia, which may worsen or not improve with surgery. Metamorphopsia is also important but doesn’t tell you if ERM is the cause of the blurred vision.
Preoperative counseling before cataract surgery is important. Sometimes the patient only needs cataract surgery and not retina surgery, but sometimes the distortion can become more obvious after CE IOL. ERM may progress early after cataract surgery and could also increase the rate of CME (especially in diabetics). OCT can also help determine PVD status, Dr. Law said. Preoperative cataract counseling should include retina consultation to determine timing.
Editors’ note: Dr. Law, Dr. McCabe, and Dr. Riaz have no relevant disclosures.
Cornea, glaucoma, and retina
Other presentations on Saturday morning highlighted cornea, glaucoma, and retina topics.
Sumitra Khandelwal, MD, discussed neurotrophic keratitis (NK), noting that there are many different etiologies. Take a step back and look at the average patient you see in a normal clinic day, she said, adding that NK is more common than you think. You don’t need fancy equipment to check for this.
Staging of NK is also important, Dr. Khandelwal said, mentioning mild, moderate, and severe stages, but patients can go from mild to severe quickly. It’s also important to understand the pathophysiology.
Lastly, Dr. Khandelwal discussed treatment options available for NK, which include artificial tears, autologous serum eye drops, antibiotics, Oxervate (cenegermin-bkbj, Dompe), tarsorrhaphy, bandage contact lens, and amniotic membrane. She also mentioned corneal neurotization.
W. Barry Lee, MD, discussed the importance of watching for keratoconus, and he shared some specific things to look for. Look for warning signs in medical history, including history of eye rubbing and family and genetic predispositions. It’s also important to look out for visual complaints like blurred vision, distortion of images, and photic-related complaints (halo, glare, starburst). Finally, he highlighted looking for refractive anomalies like distortion of mires on keratometry, error messages on autorefractors, unsatisfactory attempts at vision correction and progressive loss of UCVA and BCVA, and increasing astigmatism.
Steven Yeh, MD, Dr. Law, Manjool Shah, MD, and David Crandall, MD, shared what they “wish cataract surgeons knew” relating to retina and glaucoma.
When dealing with complex patients, Dr. Yeh said sometimes surgeons want the best outcome for the patient on postop day 1. “But I value the conversation with the cataract surgeon about what the next step will be,” he said.
Dr. Law said that if you have a diabetic patient with a previous history of diabetic macular edema, be cautious going into cataract surgery without it being resolved. It’s important to look at the macula with an OCT.
She added that too often, there will be patients with PDR or a history of ischemia and the vision is poor because of PCO. She cautioned against doing YAG immediately because there may be VEGF floating around. An intact capsule helps hold back VEGF in the vitreous, and it’s important to get retina colleagues on board.
Dr. Shah said that since cataract surgeons don’t just see cataract patients, it’s important to take every opportunity to manage glaucoma interventionally. If you learn a MIGS or another procedure, you’ll see the difference in the trajectory you can have on patients, he said.
Dr. Crandall similarly stressed the importance of learning intraoperative gonioscopy. It’s easy to transition among different MIGS procedures when you know how to do this, he said.
Editors’ note: Dr. Crandall has no relevant disclosures. Dr. Khandelwal has a relevant disclosure with Dompe. Dr. Law has no relevant disclosures. Dr. Lee has a relevant disclosure with Glaukos. Dr. Shah has relevant disclosures with a variety of ophthalmic companies. Dr. Yeh has relevant disclosures with Alcon and Bausch + Lomb.
Best of ASCRS: What the Faculty Learned This Year
During the Saturday afternoon session, ASCRS Summer Meeting faculty shared some of the many quality papers from the ASCRS Annual Meeting.
Dr. Shah shared a paper by Eli Cehelyk and colleagues at Wills Eye Hospital about family glaucoma risk communication: a community-based online intervention. Their paper recognizes that first-degree relatives of those with glaucoma are more likely to have glaucoma, Dr. Shah said, and the approach involved creating an app where patients were able to pre-populate a text message to send to family members, notifying them of the risk. While there was limited data so far, Dr. Shah said he was interested in this paper because glaucoma screening strategies have time and time again failed to be useful or cost-effective. Those who are first-degree relatives of patients with glaucoma are at high risk, so targeting them is a good way to make screening cost- and resource-effective.
Zachary Zavodni, MD, shared a paper on losartan inhibition of myofibroblast generation and late haze (scarring fibrosis) after PRK in rabbits. One thing that Dr. Zavodni said he took from the paper is the fact that myofibroblasts are dynamic, not static. Because of this cycle, if you can break it with losartan, that’s how you can get resolution of scars months or years later. In the study, topical losartan decreased scarring fibrosis and myofibroblast generation after PRK in rabbits compared to vehicle. Dr. Zavodni noted that this was a relatively short-term study, but he said that this is “the tip of the iceberg,” and he’s interested to see research and potential applications in the future for losartan for scarring related to infectious keratitis, chemical burns, trauma, Stevens-Johnson syndrome, numerous glaucoma applications, and more.
Several other papers were shared during the session, including a cornea paper on research into corneal cell therapy that focused on the safety and efficacy of human corneal endothelial cells in combination with different concentrations of rho kinase inhibitor for corneal edema secondary to endothelial dysfunction, and a paper that discussed long-term visual and patient-reported outcomes of small aperture IOLs in post-refractive eyes.
Editors’ note: Dr. Shah and Dr. Zavodni have no relevant disclosures.
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