- “Having ‘The Talk’”
- Best Videos Ever! Part 2
- Controversies in anterior segment surgery
- Cornea from A to Z
“Having ‘The Talk’”
While there a lot of different technologies that can give patients excellent refractive results after cataract surgery, Richard Tipperman, MD, said that this area keeps expanding and improving all the time. As more options become available, it increases the complexity of talking to patients, helping them understand the options, what’s best for them, and managing their expectations.
This is what the symposium Having “The Talk” focused on Monday morning.
David F. Chang, MD, shared his tips for explaining presbyopia-correcting lenses to patients. “Having so many great choices is a double-edged sword,” he said, adding later that we have to be effective in explaining the different options that patients might be candidates for, but we’re busy, and we need to be efficient.
He tells patients that everyone gets one of three types of lens implants: 1) single focus, 2) extended focus, or 3) multiple focus. “I keep it as simple as possible.” He describes their vision and visual potential with a grading system. For example, a patient who says they see fine with a 3–4+ NS, he describes their vision as a C+ or B- with their cataract, but they could achieve an A after surgery. However, a patient with a macular membrane won’t get an A after surgery but maybe a B or B+. This helps set expectations.
Then, in a 5 minute video patients watch while their eye is dilating, Dr. Chang describes the eye like a camera that sees in four zones (or distances): Zone 1: far distance (street signs, golf ball, TV captions, theater stage), Zone 2: indoor distance (kitchen wall, faces across the dinner table), Zone 3: arm’s length (desktop computer, dashboard, store shelves), Zone 4: reading distance (menu, cellphone, laptop). Dr. Chang tells them the zone they’re in now, reviews their current glasses, and talks about the zones patients could see with different lens options: single focus/distance: zone 1 or 2; single focus near: zone 3 or 4; monovision: zone 1 and 4; “blended” vision: zone 1 and 2; multifocal IOL: all zones; EDOF IOL: three out of the four zones.
He also talks about quality vs. convenience with the patients to help them understand the compromise they will need to make with the different options. Putting, he said, is a good analogy. With post-LASIK patients, for example, he’ll say he is no longer putting on a flat green; it’s uneven and it might be more difficult to achieve the desired result.
Cathleen McCabe, MD, talked about the patient conversation involving toric IOLs. Her observations start from the moment she enters the room. She sees if the patient is reading and if so, using glasses? Who did they bring with them? Are they holding a stack of papers or a gaggle of glasses? Are they smiling or have their arms crossed? Instead of saying “Nice to meet you,” she said she’ll say, “so nice to see you,” because it might not be the first time she’s meeting them.
She’ll then say, “I understand you’re not seeing as well as you’d like,” and asks if they’re having trouble with their vision. The patient’s response helps confirm they’re hearing her and gives info on their chief complaints. Then she’ll go through what diagnostic testing has helped her learn with them, followed by an overview of her findings, and a summary of their ocular health.
If they have astigmatism, she’ll inform them that they have an optical condition that can affect their quality of vision and that it’s important to treat at the time of cataract surgery. She said she’ll discuss the limitations of glasses for astigmatism. She also shared her discussion nuances for the patient who has mixed astigmatism.
Dr. McCabe tells her patients, “You have to choose where you want to see and how independent you want to be from glasses after,” but she also tells them there are no bad choices.
Other presentations in Having “The Talk” included pearls for the counseling process as well as the business/financial side of the premium lens practice.
Editors’ note: the physicians have financial interests with various ophthalmic companies.
Best Videos Ever! Part 2
In this Monday afternoon session, Robert Osher, MD, presented a number of videos, which were discussed with panelists Douglas Koch, MD, Richard Lindstrom, MD, and David F. Chang, MD.
One of Dr. Osher’s videos discussed “the zonular challenge.” He said that early on with the phacoemulsification technique, Charles Kelman, MD, made it clear that the loose lens was a contraindication to phaco.
Dr. Osher wondered why phaco machines only offered maximum or minimum. He was looking for something that allowed surgeon control, and he described his slow motion phaco approach. Surgeon controlled allowed the following five contraindications to be addressed: the mature lens, the small pupil, the shallow chamber, the compromised cornea, and the loose lens.
Several technologies came along to address when the zonular support was severely damaged, Dr. Osher said. He mentioned seeing a video that showed the capsular tension ring being used for zonular instability.
Dr. Osher followed this by discussing his idea to create synthetic zonules. He described when Robert Cionni, MD, implanted a CTR and intraocular lens into the capsular bag, and Dr. Osher said this was the first such operation in the U.S. Dr. Cionni realized a modification was necessary to recenter and permanently fixate the capsular bag, and the Morcher Cionni ring was developed in 1997, he said.
Videos began to appear from surgeons around the world, Dr. Osher said, adding that the loose lens captured the imagination of the innovative surgeon. He mentioned the Ahmed capsular tension segment, the capsular anchor, the Malyugin ring, the Henderson CTR, the capsule retractor, and more. He also mentioned a number of techniques that were developed and updated. Every year, we continue to see new devices from around the world, Dr. Osher said, adding that some new things he’s seen include a capsular bag transplant and harvesting a capsular bag from a cadaver eye used to support an intraocular lens in an aphakic patient. “We have, in fact, conquered the loose lens,” he said.
In a panel discussion of the video, Dr. Chang recalled his first phaco in 1983. “We did it and learned how to do it and we evolved,” he said. He also remembered a live surgery he did in China where he noticed that performing phaco was harder than usual, only to discover at the end of the case that surgeon control wasn’t on.
Dr. Lindstrom said that it’s a global collaboration, and technology keeps getting better. He estimated that there would be another shift from phacoemulsification to phaco aspiration in the future and that it will be physiologic or slow motion phaco aspiration. Dr. Osher made a counterargument that phaco aspiration has already been around for some time and hasn’t gained much traction, but he said as long as there continue to be changes for the better, that’s positive.
Another of Dr. Osher’s videos warned about patients with preexisting double vision. He discussed a solution he found for this by offering patients to have one eye with emmetropia and one eye myopic.
Dr. Osher said the benefit package for the diplopia patient might include uncorrected clear distance vision, unaided clear reading vision, and no more double vision. When using this, he targeted plano in the first eye and created significant myopia between 3–3.5 D in the second eye. The patient could select which eye he or she preferred for distance, and this didn’t always respect ocular dominance, he said.
Looking at a small number of patients, Dr. Osher said that all patients achieved excellent uncorrected distance, and all achieved clear unaided near vision. Double vision was completely absent in 83.3% (10 patients).
Editors’ note: The physicians have financial interests with a variety of ophthalmic companies.
Controversies in anterior segment surgery
The JCRS symposium Monday morning tackled three controversies in anterior segment surgery: the best technique for capsulotomy creation in white cataracts, controlling inflammation post-cataract surgery, and whether phaco alone or phaco plus MIGS is sufficient for early to moderate glaucoma.
Rengaraj Venkatesh, MD, discussed why he thinks the manual capsulotomy is the preferred technique for intumescent cataracts. He shared various publications that show different safe and effective manual methods for capsulotomy in these cases. Several newer technologies seeking to automate capsulotomy in intumescent cataracts come with some issues, he continued. FLACS, for example, is expensive, has a large footprint, and the capsule edge can have tags, be irregular, or have aberrant holes. With ZEPTO (Centricity Vision), he said, there can be an inability to open the device in the eye, suction loss, endothelial cell loss potential, and difficulty in shallow anterior chambers. CAPSULaser (EXCEL-LENS) results in a smooth, rolled edge with demonstrated superior tensile strength, but Dr. Venkatesh questioned why we need so much strength. “Too much of anything is good for nothing sometimes,” he said.
Nicole Fram, MD, spoke about the benefits of FLACS in intumescent cataracts. Why do we need a better way than manual for these cases? She shared several papers that support the safety and efficacy of FLACS with intumescent cataracts and said it takes the most difficult part of the surgery and makes it simple. She doesn’t think, however, it should be used on all white cataracts, advocating for the use of intraoperative OCT or UBM to look at what are good cases (avoiding it with spheroid lenses).
Vance Thompson, MD, spoke about ZEPTO. He said he finds the suction cup is easy to put in, suction reliable, and called it an “amazingly reproducible technology using Purkinje images,” producing an edge that is smooth and quite strong. With the capsulotomy created in 4 milliseconds once the energy is delivered, he said it minimizes the chance of extension. Cases in which Dr. Thompson said he does not feel comfortable using ZEPTO are those with deep anterior chambers and small pupils.
Finally, Richard Packard, MD, offered his perspective on CAPSULaser, which is a selective laser capsulotomy creation technology. He said capsulotomy creation with CAPSULaser avoids the Argentinian flag sign by creating a pressurized AC with high molecular weight OVD. It is well centered based on the use of microfiltered trypan blue to identify the anterior capsule and its landmarks; the trypan blue capsular landmark identifies the visual axis on patients who cannot fixate. He also said the laser capsulotomy is a consistent, circular size with a strong elastic edge created in 0.3 seconds, offering 360-degree IOL coverage, which can assist in PCO prevention.
Dr. Packard said in more than 20,000 eyes, there have been no cases of Argentinian flag sign.
Two awards were also given in the session. The JCRS Obstbaum Award, given for a full-length article, went to Pantanelli S., et al. for “Vision and patient-reported outcomes with nondiffractive EDOF or neutral aspheric monofocal intraocular lenses.” The JCRS Mamalis Award for a paper in laboratory science was given to Lago C., et al., for “Computational simulation of the optical performance of a EDOF intraocular lens in post-LASIK eyes.”
Editors’ note: Dr. Thompson has financial interests with Centricity Vision. Dr. Packard has financial interests with EXCEL-LENS. Dr. Venkatesh has no related financial interests.
Cornea from A to Z
A Monday morning symposium focused on medical and surgical cornea issues, with a case-based interactive format.
Kourtney Houser, MD, shared a case of a 66-year-old female who came in with fluctuating blurry vision and glare. Th right eye was really uncomfortable, and Dr. Houser used a fluorescein strip to stain.
Dr. Houser noted that the problem was actually concretions on the lid, which correlated with the areas of stain, and these were linear and clustered.
Conjunctival concretions, she said, are degenerating epithelial cells with some mucinous secretions from conjunctival glands. These are due to chronic inflammation, she said, and associated with a lot of areas like aging, MGD, atopic/vernal conjunctivitis, and trachoma.
Most of the time, they’re asymptomatic, Dr. Houser said, but these patients can have symptoms if they stain. She said she will treat If they bother the patient, but she might just do them at the slit lamp. These concretions usually come out easily, Dr. Houser said, but there may be a little bleeding.
For this patient, she removed the concretions in both eyes, and put the patient on a steroid and antibiotic to help with irritation and prevent infection. The patient probably had about 20 exposed concretions in each eye, Dr. Houser said. The patient has experienced this problem previously, so Dr. Houser also put her on a chronic anti-inflammatory drop.
These concretions are more common than we think, said Marjan Farid, MD. When she sees this problem, she said that patients often come in saying the pain is constant and localized. It’s on us to flip the lid and really look for these, she said.
Francis Mah, MD, said he often sees these when they haven’t broken through yet. “I don’t actively try to remove them when patients aren’t symptomatic,” he said. But he added that he will advise aggressive therapy for the eyelids.
Editors’ note: The physicians have financial interests with various ophthalmic companies.
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