- William Link, PhD, delivers the Charles D. Kelman, MD, Innovator’s Lecture
- Symposium showcases classic, award-winning videos
- Cataract crossover
- ASOA Monday General Session
- Learning from the ‘perfect save’
- Managing complex cases
William Link, PhD, delivers the Charles D. Kelman, MD, Innovator’s Lecture
William Link, PhD, was honored with the Charles D. Kelman, MD, Innovator’s Award and delivered the distinguished lecture on Monday from the ASCRS Main Stage.
“What an honor to have the opportunity to receive this award,” Dr. Link said. “Charles Kelman had a real impact on my life. I learned a lot from him.”
Innovation is special in the field of ophthalmology, Dr. Link said. Vision is valued, and even with decades of innovation and commitment, worldwide there are still immense unmet needs. Innovation has been rewarded in the field of ophthalmology, which is precious because as Dr. Link put it, “resources come to areas where they’re rewarded.” The market—patients, providers, investors, entrepreneurs, and strategic leaders—is receptive to innovation in ophthalmology.
The ecosystem for innovation is well established in this area of medicine, Dr. Link continued, noting that he’s been involved in ophthalmic innovation for 4 decades. He served as the president and founder of American Medical Optics beginning in 1978; this company was then sold to Allergan in 1986, spun out as Advanced Medical Optics in 2002, was acquired by Abbott in 2009, and was acquired by Johnson & Johnson Vision in 2017. He was the CEO and founder of Chiron Vision in 1988, which was later sold to Bausch + Lomb in 1998. He also led one of the first ophthalmology focused venture capital firms, Versant Ventures, and founded Flying L partners in 2016. Dr. Link has founded or invested in 28 companies in ophthalmology and helped create new market categories.
Dr. Kelman, upon meeting Dr. Link in 1978, asked if Dr. Link would help him make an IOL. This would eventually lead to the Kelman Tri-pod lens in 1979.
“Through the decades, not only did we have a lot of personal and professional interaction, but he welcomed me and my family into his family,” Dr. Link said. Later in his presentation, he said that for innovation, the power of relationships matter.
Dr. Link shared a story about he and Dr. Kelman playing golf. On the course, they started talking about ideas. After the golf game, they took his helicopter to Dr. Kelman’s Manhattan practice and while on the walk there, Dr. Kelman made a call to his patent attorney. After seeing a few patients in his office, he had a fax of a draft patent. He provided his edits, faxed it back, and returned to seeing patients. By the end of that same day, Dr. Kelman had a filed patent.
“He had resources that were so responsive and knowledgeable around him. He didn’t want to think about it and noodle on it. He took action now. That was just wonderful learning,” Dr. Link said.
Dr. Link shared his key characteristics of innovation.
- Character counts
- Take initiative (when it doubt, give it a try)
- Good manners and high integrity
- Build trust relationships
- Hire great people, inspire, and empower them
- Be a great communicator
- Listen more than you talk
- Hard work pays off
- Take calculated risks
- Don’t take yourself too seriously
“Remember, innovation is powered by courage, courage to fail, courage to try things,” Dr. Link said. “[It is] powered by determination. … [And] if we’re willing to let others share the credit for innovation, it’s more powerful. So, humility amplifies the impact of innovation.”
Editors’ note: Dr. Link has financial interests with a variety of ophthalmic companies.
Symposium showcases classic, award-winning videos
Robert Osher, MD, moderated a symposium focused on award-winning videos from his video library, showing not only his own creations but those of other physicians as well.
The first video was from Howard Gimbel, MD, who presented it in 2004. The video was about the six variations of optic capture, which he called a rescue technique when you need a stable lens but have a bag with lost integrity. These techniques included:
- Optic capture by the anterior capsulorhexis where the haptics are in the sulcus and the optic pushed through the capsule opening.
- Optic capture by anterior capsulorhexis, but this time, the haptics are in the bag and the optic is pulled out of the bag.
- Optic capture by the posterior capsulorhexis where the haptics are in bag and the optic is behind posterior capsulorhexis.
- Optic capture by posterior capsulorhexis where the haptics are in the sulcus and optic behind posterior capsulorhexis. He said to use this technique in the event of a large anterior capsule tear.
- Optic capture by capsular membrane where the haptics are in the sulcus and the optic behind the membrane.
- Optic capture by membrane where the haptics are in the posterior segment and optic pushed through opening in the membrane. He said this technique could be used by vitreoretinal surgeons after vitrectomy.
Graham Barrett, MD, on the panel, said this video shows such fundamental techniques that, over time, you can forget where it all came from.
The next video was from Dr. Osher in 1997. He challenged the idea that sharp edges from mature cataracts were creating posterior capsule tears. In the video, Dr. Osher showed research that debunked this widely held idea. In the lab experiments, pieces of a dense cataract were pushed and tumbled around inside a capsular bag, with no tears occurring. He even demonstrated that the bag didn’t tear when the same experiment was done with small, sharp pieces of igneous rocks. In the video, he provided the possible explanations for why surgeons had “perpetrated this theory.” He then concluded that the evidence shows the sharp edges of dense cataracts are not causing this complication, rather it is certain actions by the surgeon.
Douglas Koch, MD, on the panel, said that this video shows the possible real causes of posterior capsule tears, so surgeons can modify their steps during surgery and try to eliminate the problem.
Editors’ note: The speakers have no financial interests related to their comments.
Cataract crossover
The cataract crossover symposium addressed cataract surgery in patients with oculoplastic disease, retinal disease, glaucoma, neuro-ophthalmic disease, and corneal disease.
Inder Paul Singh, MD, shared during his presentation on cataract surgery in patients with glaucoma how to prevent hyphema. Don’t let the eye shallow during surgery, he said. Keep the head elevated during and after surgery. He doesn’t stop blood thinners. He also said to hyper-inflate the eye at the end of the case, but slowly decompress the eye.
Sarah Read, MD, PhD, discussed cataract surgery in patients with retinal disease, first mentioning the importance of a rigorous informed consent for comorbid conditions. She highlighted some preoperative planning and postoperative considerations for these patients.
Age-related macular degeneration often goes along with cataracts and the aging population, Dr. Read said, and she suggested considering the use of OCT. Mild AMD can still show contrast sensitivity. Dry macular degeneration, even when central vision is limited, can benefit from cataract surgery, brighter vision, and more peripheral vision. AMD is a progressive disease, she said. The variability of risk is all over the place when you get to intermediate AMD. Even in patients with a good immediate postop outcome, you need to prepare them that the lifespan of visual improvement may be limited.
Geographic atrophy gets bigger with time, Dr. Read said, adding that you lose about an average of 3 lines over 2 years. There are several new treatments to slow the progression of atrophy, pegcetacoplan and avacincaptad. But Dr. Read said this functionally shouldn’t change treatment/counseling.
In wet AMD, she said to wait until the disease is somewhat controlled before cataract surgery. Dr. Read also discussed diabetic retinopathy, high myopia, and diseases of the vitreomacular interface.
Postoperatively, she said that retinal detachment/tears and cystoid macular edema (CME) are the two main issues after surgery.
Editors’ note: Dr. Singh has financial interests with a variety of ophthalmic companies. Dr. Read has no financial interests related to her comments.
ASOA Monday General Session
ASOA President Patti Barkey, COE, began the session by recognizing ASOA Executive Director Laureen Rowland, CAE, who is retiring at the end of the year, after 12 years with the organization.
Ms. Rowland took the stage to give some remarks. “My career has spanned over 40 years in association management,” she said. “The last 12 years of ASOA have truly been the pinnacle of my association management career.”
Leslie Riley was the guest speaker of the session, guiding attendees on how to take all the ideas they’ve learned at the ASOA Annual Meeting and follow them into something that will be useful.
Goal setting changes over time. “When we think about goals, we have to think that we’re setting a direction for where we want to go, but we might have to hit the brakes sometimes,” she said. Goal setting fluctuates over time.
Ms. Riley told a story about trees in the rainforest that are like their own ecosystem. There are a bunch of leaves that fall to the ground around these trees, and these leaves help nurture the trees because the soil is shallow and doesn’t have enough nutrients. As leaves fall, they decay, and the nutrients from the leaves nurture the trees. Ms. Riley likened attendees in the room to these leaves, helping the industry to grow. “Whether you’ve been in the industry a decade or a day, you have a perspective, and you know things,” she said.
She went on to discuss the shape of a conversation. When you use your voice, you tap into inner wisdom, and when you do that as a team, magic can happen, she said.
When having a good conversation, she said, there should be a clear purpose for getting together and objectives that you’re aiming for. Then, you need to determine clear outcomes, action items, and next steps that you’re aiming for.
Ms. Riley further discussed having a good conversation. The purpose, she said, is to turn conversations and ideas into at least one actionable step you commit to doing after the conference ends. Her goals for attendees in the Monday session were to listen and contribute; discover new insights about your industry, organizations, teams, and even yourself to help you better perform in your current role; and to inspire and be inspired. “Have your ears open for something that’s an ‘ah-ha’ or insight,” she said.
Ms. Riley highlighted four levels of goal setting:
- Self – What are my career goals? What step is next for me on my path? What skills do I need to be successful?
- Team – How do we tie into the bigger picture? What barriers get in the way of us delivering? What relationship skills do we need?
- Organization – What are our current areas of growth? How do we learn from other practices our size? Where do we want to be in 5 years?
- Industry – What is happening in our industry that may shape future policies? What new technology has been recently introduced or is being worked on? What disruptions have caught us off guard?
Editors’ note: The speakers have no financial interests related to their comments.
Learning from the ‘perfect save’
A case-based symposium sponsored by the International Intraocular Implant Club focused on complex cases with a “perfect save.” The symposium included video cases as well as presentations on new technology that could provide that perfect save.
Rudy Nuijts, MD, PhD, showed how he handled a cataract case with phacodonesis at the slit lamp. In the OR, the lens was wobbling and moving, making it difficult to pierce the lens. Creating the capsulorhexis was also difficult. After needing to enlarge the capsulorhexis with scissors snips several times, Dr. Nuijts put in capsular tension hooks and used a divide and conquer technique. He said he used a bimanual technique to rotate the nucleus to avoid more stress on the zonules. Once the lens was removed, Dr. Nuijts scleral sutured a Cionni ring. Then he put in the lens. “The trick is that you should fixate and center the lens, then apply tension to the suture at the end and judge how the lens is going to center in the eye,” he said. At postop month 1, the patient had a CDVA of –1.5:–2×40°:0.8–. The capsulorhexis was oval but had good centration and the IOL good stability.
Moderator Ronald Yeoh, MD, asked why Dr. Nuijts didn’t do FLACS for the capsulorhexis. Dr. Nuijts said it might not have been available that day but acknowledged that it also might have been a misjudgment.
Sri Ganesh, MD, shared a case involving a 16-cut post-RK patient. The topography showed extreme flattening of the cornea and irregularity. Biometry showed a need for a 32.5 D lens, but it only went up to 31 D. He used anterior optic capture of the 31 D IOL to shift the effective lens position and induce a 2 D shift with the lens. Postop, the patient was UCVA 6/9 blur at distance and N6– at near. “I got lucky,” Dr. Ganesh said.
Editors’ note: The speakers have no financial interests related to their comments.
Managing complex cases
Nicole Fram, MD, presented on managing dysphotopsia. Pertaining to negative dysphotopsia, she shared her “top 5 questions” to ask patients.
- When did the symptoms begin?
- Were you happy 1 month after the surgery?
- Do you have a dark arc/shadow? And does it come and go? And is it better with dilation?
- Are your symptoms worse with oncoming or oblique light?
- Is it annoying or debilitating?
She also shared some non-surgical management options for negative dysphotopsia. First, she said to give it some time, adding that 97% of negative dysphotopsia resolves by 1 year. She advocated for dark, thick-rim glasses. It’s better with dilation, she said, though this is not practical. Dr. Fram also mentioned contralateral opaque contact lenses as an option.
Mitchell Weikert, MD, offered his pearls for in-the-bag and open capsule IOL exchanges. He recommended scheduling these cases at the end of the day when you have a little more time and to take your time.
Pearls included:
- Elevate the anterior capsule
- Avoid overfilling viscoelastic
- Inject OVD along the optic-haptic junction
- Enlarge the capsulorhexis
- Implant the CTR if you’re concerned about the zonules
- Enlarge the capsulorhexis with the femtosecond laser (particularly if you have a fibrotic capsule)
- Rotate scissors to a 45-degree angle to keep the IOL flat
- Consider folding the IOL to remove
- Open PC with a vitrector for posterior optic capture (if you have an open capsule)
- Amputate haptics to improve mobility
Editors’ note: Dr. Fram and Dr. Weikert have financial interests with a variety of ophthalmic companies.
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