- Charles D. Kelman, MD, Innovator’s Lecture
- Richard L. Lindstrom, MD, Lecture
- Cataract Olympics Gold Medalists
- WhatsApp? International symposium looks at anterior segment dilemmas
- High impact pearls
Charles D. Kelman, MD, Innovator’s Lecture
David F. Chang, MD, gave the Charles D. Kelman, MD, Innovator’s Lecture on the topic of “Frugal Innovation,” saying this is “the key to tackling our greatest challenges.” We tend to think of innovation in terms of cutting edge, new, expensive, Dr. Chang said, adding that ASCRS was founded to advance a controversial new technology.
He described frugal innovation with the term “jugaad,” or trying to come up with an inexpensive alternative to necessary technologies. Can we reach more people with a more cost-effective solution that’s long term but still maintain our outcomes? he questioned.
The biggest challenge is the great backlog of global cataract blindness, Dr. Chang said. What has changed is we still have that burden, but it’s going to be a future problem of access in high income countries, he said. There is increased demand, insufficient manpower, and sustainability concerns.
Dr. Chang used the Aravind Eye Care System as an example of minimizing the footprint of cataract surgery. He mentioned manual small incision cataract surgery (MSICS), a high-volume surgery model, square-edge PMMA IOL, intraocular moxifloxacin, and surgical supply/device reuse.
Aravind, he said, is not using the phaco machine to do surgery. They are using MSICS. He mentioned a case comparison he did in Nepal with Sanduk Ruit, MD, that showed that the outcomes with phaco and MSICS were basically the same. Furthermore, the complication rates were actually higher in low-income settings with phaco because of the lack of training, so MSICS might be a safer option in those areas.
The high-volume surgery model involves maximizing surgeon efficiency/productivity/volume by doing 10–15 cases per hour, Dr. Chang said. It requires standardization in every OR and with procedures. Everyone does the same thing in the same order.
If you square a PMMA edge, it’s just as good as foldable IOLs, Dr. Chang said. Intracameral moxifloxacin was approved in India, and he noted data of this being used successfully. In terms of surgical supply/device reuse, the healthcare system is a big contributor to this problem. As our cataract volumes increase, so too will disproportionate contribution to landfill and carbon emissions. Dr. Chang discussed how Aravind reuses things like surgical gowns, gloves, phaco cassettes, I/A tubing, irrigation bottles, cannulas, blades, sutures, intraocular drugs, etc.
Dr. Chang said there is a reason to be optimistic that we could cut down on spending and waste without endangering patients. During his lecture, Dr. Chang also discussed EyeSustain, and he also got into updates in robotics, mentioning the ORYOM (Forsight Robotics).
Editors’ note: Dr. Chang has financial interests with Alcon, Forsight Robotics, Johnson & Johnson Vision, and Zeiss.
Richard L. Lindstrom, MD, Lecture
Renato Ambrósio Jr., MD, PhD, gave the Lindstrom Lecture on Sunday, saying giving this lecture is “one of my highlights of my career.” He began the lecture by sharing quotes from other ophthalmologists about the impact that Dr. Lindstrom has had on the ophthalmic field.
Dr. Ambrósio’s lecture focused on refractive surgery, highlighting going “beyond.” Refractive surgery is a scientific subspecialty of ophthalmology, with elective procedures that aim for refractive correction. But what is the goal? The goal of refractive surgery is to improve patient satisfaction, quality of vision, and quality of life, he said. We should consider that refractive surgery eventually should evolve to be a specialty medicine, Dr. Ambrósio said. It’s not just elective procedures but therapeutic as well.
It’s important that we customize, Dr. Ambrósio said, mentioning preventing complications like progressive keratectasia, tear dysfunction/ocular pain, interface epithelialization, quality of vision symptoms, and over/under sizing phakic IOLs.
Dr. Ambrósio expanded on the “beyond” theme to discuss imaging in refractive surgery. He highlighted a number of modalities and also mentioned the role of artificial intelligence.
Screening for keratoconus and ectatic corneal disease is also important. He noted screening, characterization of ectasia susceptibility, confirming the diagnosis, staging, and classifying as some of the “whys” in diagnostics of these diseases. Dr. Ambrósio said that one of the most important ways to avoid ectasia is to tell people not to rub the eye.
Also “beyond” refractive surgery, Dr. Ambrósio highlighted the role of biomechanics. He went on to describe the enhanced ectasia susceptibility score (EESS) and his work on BrAIN (Brazilian Artificial Intelligence Networking in Medicine) software that applies artificial intelligence to quantify the impact of laser vision correction in a relational thickness-altered (RTA) approach, combined with the characterization of ectasia susceptibility. He also mentioned artificial intelligence for ICL sizing.
What is the difference between a standard cataract surgery and refractive cataract surgery?
Dr. Ambrósio said the difference is refractive planning. Ectasia assessment is relevant for refractive cataract surgery because of the impact on the accuracy of IOL power calculation, the impact on quality of vision after premium IOLs, and the impact on safety and efficacy of secondary corneal LVC.
Refractive surgery is a mindset, Dr. Ambrósio said. “We’re all here to learn and … continuously evolve to the best version of ourselves.”
Editors’ note: Dr. Ambrósio has financial interests with a variety of ophthalmic companies.
Cataract Olympics Gold Medalists
The Cataract Olympics symposium brought together teams from ASCRS, APACRS, ESCRS, and LASCRS who competed for gold medals in various cataract categories. These were the gold medal winners (as voted by the audience) in each category:
Cataract Technology Hurdles: Robert Ang, MD, APACRS: Dr. Ang presented his MMA technique—mastering maneuvers for alignment—of toric IOLs. He said for C-loop toric IOLs, use the “BIG APA” technique.
- I/A BENEATH the IOL.
- INJECT GEL over the IOL.
- ALIGN the IOL to the axis.
- PATIENTLY wait for 1 minute.
- ASPIRATE remaining gel.
For double C-loop and plate haptic IOLs, use AUTO.
- ALIGN the IOL to target axis.
- Use I/A UNDER the IOL.
- Fine-TUNE the axis alignment.
- I/A OVER the IOL.
IOL Wrestling: Ike Ahmed, MD, ASCRS: Dr. Ahmed shared a case of IOL exchange with an open posterior capsule. The patient was a few years postop, had prior YAG, and was unhappy with their toric EDOF. The challenge in this case was to keep the posterior capsule intact and not get any vitreous prolapse.
Dr. Ahmed showed how he used multiple incisions and the right instrumentation. With microforceps he held the anterior capsule, using a Sinskey hook to push down the lens. Using the blunt edge of the visco cannula, he gently dissected. He stressed doing a blunt dissection with judicious use of cohesive viscoelastic. From there, he followed with dispersive OVD to coat the open vitreous space to prevent it from coming forward.
With the haptic pretty fibrosed, he cut the optic and gently rotated it out of the bag from a 2.2-mm incision. He slowly injected dispersive viscoelastic to coat the anterior hyaloid face and proceeded with a “handcuffing technique” to insert the toric IOL (suture-tied haptics). Once the IOL was rotated to the correct axis, he cut the suture and opened the haptics.
Cataract Surgery Gymnastics: Randall Ulate, MD, LASCRS: Dr. Ulate said that Yamane has become one of the most popular techniques to manage aphakia in patients without capsular support. He, however, expounded upon the technique, showing it in more complicated scenarios, such as aphakia and a large iris defect. He showed how the three-piece IOL could be used as a scaffold to hold a prosthetic iris that is then all sutured to the sclera using the Yamane technique. He also showed this same technique but in the case of an open sky surgery followed by a PK graft.
The overall team gold medal went to ASCRS in the session.
Editors’ note: Dr. Ulate has no relevant financial interests. Dr. Ahmed and Dr. Ang have financial interests with a variety of ophthalmic companies.
WhatsApp? International symposium looks at anterior segment dilemmas
A Sunday morning symposium brought together leadership and members from ASCRS, LASCRS, APACRS, and ESCRS for presentations on common anterior segment dilemmas and solutions from around the world. Here’s a recap of a few presentations from the session.
Thomas Kohnen, MD, PhD, representing ESCRS: Dr. Kohnen discussed managing high vault after phakic IOL implantation. He presented a case involving a 23-year-old patient with high myopia and astigmatism who sought spectacle independence. The STAAR nomogram recommended a 13.2 mm ICL, however, postop, in the patient’s right eye, photophobia and halos resulted due to hypervault. Dr. Kohnen showed the vault was 1,470 microns. The decision was made to exchange the lens. Postop after ICL exchange, the patient was 20/25 UDVA and their optical symptoms and satisfaction improved.
Dr. Kohnen said the most important measurement for ICL is white-to-white, but he noted that this can be difficult to measure, and there are differences between the devices. He shared a paper that looked at different ICL sizing nomograms that found the Kim, Rocamora, Russo, and Reinstein nomograms were the most predictive with ACD, CBID, and pupil diameter being important for future nomograms.
Tun Kuan Yeo, MD, representing APACRS: Dr. Yeo presented on IOL calculations in subluxated cataracts, emphasizing that the challenge is that the measurements obtained for IOL calculations in these cases are not physiological. So, what’s your choice of IOL formula? “This is a problem we face in my practice,” he said. “We know modern IOL formulas perform well, but they require multiple parameters.” These parameters, again, can be affected by the non-physiologic measurements that can be obtained with these eyes. Dr. Yeo went on share IOL formulas that were compared for eyes with subluxated cataracts based on normal anterior chamber depths, those 2 mm or less, and those more than 3 mm.
Cesar Carriazo, MD, representing LASCRS: Dr. Carriazo shared a unique way he handles cataract surgery in cases of small pupils when he thinks he cannot use iris retractors due to bleeding risk. He described performing vertical chop with a “tip chop” modified phaco tip. The phaco tip, he explained, was milled to remove the top portion, making it look more like a spoon. With this tool, he said he is able to work in the center, lift the nucleus, and chop going down in a safe and effective manner.
Douglas Rhee, MD, representing ASCRS: Dr. Rhee said there is a new paradigm for the treatment of POAG. Traditionally, Dr. Rhee said the treatment paradigm was medication, laser, and incisional surgery, but this paradigm might not be the best.
“SLT is now first,” he said. “It is no longer appropriate to start a treatment naïve POAG patient with eye drops. SLT should really be first.”
Dr. Rhee said after laser in the modern treatment paradigm comes sustained-release medication. He specifically discussed the sustained-release bimatoprost intracameral implant, noting that research has shown it to be as effective as goniotomy.
According to a survey, those who are most likely to do SLT first are more recently out of residency, are more likely to also do MIGS procedures, and more than 25% of their patient population has glaucoma.
Editors’ note: the physicians have financial interests with various ophthalmic companies.
High impact pearls
The “Get H.I.P.” symposium featured presenters sharing their high impact pearls in 90 seconds or less.
Jonathan Rubenstein, MD, described his “bowl and roll” technique for soft cataracts. He noted that he’s been teaching residents for more than 35 years, and the soft cataracts often give them the most problems. Dr. Rubenstein started with hydrodissection. He then phacos and cores out the anterior cortex with a similar approach that would be used for a chopping technique. As you create a groove in the central nucleus, you extend the groove and make wider and wider. Remove as much of the central nuclear material as much as possible, he said, so the sides of the nuclear bowl start to collapse. By weakening the base, you can then roll in the peripheral cortex.
David Chen, MD, offered his pearls on placement, noting the importance of avoiding injection of OVD into a PC defect. When he injects the IOL, he injects into the anterior chamber first instead of into the bag directly. Then, drop the haptics into the bag. This minimizes rotation of the IOL, he said. After the IOL is in the bag, you can make gentle maneuvers to secure the placement, he said.
David F. Chang, MD, offered his pearl for diffuse zonulopathy. He said to fill the bag with dispersive OVD for the last fragment/cortex. This places the posterior capsule on stretch, and the PC trampolines without centrifugal zonular tension. He added to delay putting in a CTR as long as you can until after the cortex is out.
Editors’ note: Dr. Chang has no relevant financial interests. Dr. Chen has no relevant financial interests. Dr. Rubenstein has financial interests with Alcon.
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