- Binkhorst Lecture: IOL calculations in atypical eyes
- ‘X-Factor: Women Leading by Example’
- ‘X-Rounds’ roundup
- ‘Toolkit for Job Success’
Binkhorst Lecture: IOL calculations in atypical eyes
This year’s Cornelius Binkhorst, MD, Lecture was given by Mitchell Weikert, MD, who spoke on the topic of IOL calculations in atypical eyes.
He said that this is an important topic, and an area where his team at Baylor has done a lot of work. Dr. Weikert said he was also hoping that attendees would walk away with several pearls from his lecture to use in their practices.
How are we doing? Across the board, cataract surgeons are about 74% within about 0.5 D of target, he said, but can improve to 92%.
Sources of error in IOL power calculations include effective lens position, postop refraction, axial length, and corneal power. People are trying to get around this, he said. As formulas have evolved, they’ve incorporated various ways to get around or mitigate some of these sources of error, but modern formulas are black boxes. You can study how they perform, but we don’t have insight into their inner workings.
Things break down when patients’ eyes are more atypical, Dr. Weikert said. He took a quick detour to discuss statistics. There’s confusion and debate on how to best analyze performance in atypical eyes.
Dr. Weikert’s lecture highlighted four groups of atypical eyes: long eyes, short eyes, keratoconic eyes, and post-laser vision correction eyes.
Long eyes are generally thought of as greater than 25 mm. This is very common (8–16%, and you tend to underestimate IOL power, resulting in hyperopic errors).
With respect to axial length, Dr. Weikert mentioned work by Li Wang, MD, PhD, and the regression formulas by Dr. Wang and Douglas Koch, MD.
Going back to the beginning of biometry, Dr. Weikert said, as optical devices evolved, the ability to measure individual segments of the eye improved. Even though we can measure individual segments, they’re ignored when we’re given the displayed axial length, he said, adding that he did a study several years ago to look at this. We found that we could reduce prediction errors by using segmented axial lengths in some formulas.
Short eyes are axial lengths that are less than 22 mm. We tend to overestimate IOL power in these, he said, which leads to myopic errors. Factors impacting errors in short eyes are a shallow anterior chamber, thick lens, shorter vitreous cavity, and high IOL powers.
Meanwhile, for keratoconic eyes, these have variable measurements, contact lens influence. These eyes tend to underestimate IOL power, leading to hyperopic errors.
In the post-LVC eye, Dr. Weikert said, IOL power may be under- or overestimated. Myopic ablation can lead to hyperopic error, and hyperopic ablation can lead to myopic error. He said this is a common issue, noting that these are 10–14% of cataract patients at his institution.
Editors’ note: Dr. Weikert has financial interests with Alcon, Carl Zeiss Meditec, and Epion.
‘X-Factor: Women Leading by Example’
The second part of Saturday’s Main Stage session was the “X-Factor: Women Leading by Example.” It featured Malvina Eydelman, MD, of the FDA, leading a discussion with past female presidents of ASCRS, Elizabeth Yeu, MD, Bonnie Henderson, MD, Priscilla Arnold, MD, and Marguerite McDonald, MD.
Dr. Eydelman first asked Dr. McDonald about what motivated her, noting that she was the first woman to become ASCRS president and led many new developments in refractive surgery, including being the first ophthalmologist to perform excimer laser treatment. Dr. McDonald said it was really about the patient and unmet need. “I was always interested in refractive error,” she said, adding that she knew there were suboptimal surgical procedures to address this. As you start aiming, Dr. McDonald said, better procedures for patients is the North Star. “Everything else sort of falls into place if you keep that as your North Star,” she said. If you start to do the work and it’s good work, it starts to generate its own pathway for you, she said.
Dr. Arnold discussed how she and several other female ophthalmologists were in positions of leadership around the same time. She said this was likely related to a demographic change of more women graduating from medical schools and entering practice life around the 1970s–1980s. It takes a lot of time to build the practice experience, the professional relationship, many years of commitment to professional organization, and trust and confidence of colleagues, and none of us who have had leaderships roles come without standing on the shoulders of others, Dr. Arnold said. “I think that it’s critical that we involve women in leadership because as of 2022, the latest statistic I could find, medical school enrollment was at 56% of women, and if we don’t pay attention to that part of our future leadership, we will lose it.”
Dr. Henderson started by saying that she hopes the next similar panel will see a stage full of female presidents. Leadership is not just about what you’re doing now, but it’s about looking at innovation and trying to improve everything you do, she said. “I want to say that what’s really important in empowerment of women are the men. You can’t make change for the minority if the majority is not supportive,” Dr. Henderson said.
Dr. Yeu said that she is proud of the diversity within ASCRS. It’s about not only men, women, young leadership, older leadership, but it’s that whole diversity and thinking about that forward movement and what it takes to have a complete society that’s representative of its membership, she said. She showed photos of leadership on the ASCRS Executive Committee and Clinical Committees in 2014 and 2024. In 2014, there were 17 men and 3 women, but today, there are 12 men and 6 women.
Editors’ note: The speakers have no relevant financial interests.
‘X-Rounds’ roundup
“X-Rounds: Refractive Surgery to the Max” is an annual exciting symposium moderated by Eric Donnenfeld, MD, that has a panel of surgeons giving 2.5-minute, quick-hit presentations on various topics with an audience-selected winner chosen within each category.
New technology on the horizon: The audience voted for Elizabeth Yeu, MD, in this category for her presentation of low-energy cataract surgery with MICOR (MICOR Industries). The technology uses mechanical agitation to dissolve the lens. There is minimal fluid through the eye, but it maintains incredible chamber stability, firing 1,000 times less frequently than phaco at the same amplitude. Dr. Yeu said the technology is easy to use, finger-controlled (no foot pedal), has a small footprint, and features cataract removal, capsular polish, and vitrectomy, all in one handpiece.
What I’m excited about in presbyopic IOLs: Dr. Hovanesian was voted the winner for his talk on the LAL+ (RxSight). The original lens platform, he said, provided unprecedented accuracy in both sphere and cylinder. “Those of us who have used it are very committed to this platform,” he said, noting that almost 100,000 implants have been used so far.
The LAL+ has an extended depth of focus built in, giving patients an increased range of vision, Dr. Hovanesian said. This is achieved through a small continuous increase in central lens power. Dr. Hovanesian said he targets his patients just a little bit hyperopic and brings them to emmetropia.
“This is the closest thing we have no to a ‘perfect’ lens for patients,” he said.
Best tip for improving the ocular surface: Dr. Yeu took this category for her presentation on the benefits of treating Demodex blepharitis with lotilaner (XDEMVY, Tarsus Pharmaceuticals). Sixty percent of patients coming into the office have Demodex blepharitis, Dr. Yeu said. It is easily diagnosed with patients looking down, but it can also be misdiagnosed and is associated with many sequalae, including that which can lead to scarring, conjunctival issues, and more. Treatment with lotilaner can not only resolve the blepharitis, but it can do things like improve meibum quality and increase meibomian gland secretion scores. “There is huge improvement in treating Demodex and lid margin health,” Dr. Yeu said.
Editors’ note: The physicians have financial interests with various ophthalmic companies.
‘Toolkit for Job Success’
A YES lunch symposium offered mentorship on a range of topics, from fellowship to finding your first job to international work.
A panel discussed the options for practicing in academics or private setting. The session’s moderator, Kourtney Houser, MD, asked the panelists to share how they choose their current path and what they like about it.
Dagny Zhu, MD, is a cornea, cataract, refractive surgeon in private practice. She said she had a very academic background, but when she got out of training, her priority was to be in southern California. She interviewed widely but found an opportunity to buy a practice for sale in her hometown. “I hadn’t planned that, but sometimes things just happen,” she said.
Mina Farahani, MD, also said she prioritized geography when she entered practice. She said that 85–90% of us change jobs in the first few years, including herself. Her first job was at a large subspecialty private practice, and she learned from that experience she wanted a smaller practice environment. “My tip would be to get exposure to different settings when you’re in residency,” she said, adding later that it may take a couple of tries to find a good fit once out in practice.
Douglas Rhee, MD, shared the academic practice perspective, saying that it never gets boring in academics. The most important thing, he said, is that we’re in the best profession in the world: ophthalmology. From there, it’s about figuring out what you want within this profession.
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