- Managing cataract complications
- Glaucoma laser technologies
- Barraquer Lecture
- ‘Grand Rounds: Real Cases from Around the World’
Managing cataract complications
During a video symposium, presenters shared various cases where they managed cataract complications.
Surendra Basti, MD, focused his presentation on simplifying the Yamane technique, offering five pearls:
- Use the Kim modification of the Yamane technique.
- Mark accurately.
- Open the conjunctiva.
- Use a preplaced four-throw suture to avoid hypotony.
- The railroad technique differs in PVDF vs. PMMA haptics.
Editors’ note: Dr. Basti has financial interests with Johnson & Johnson Vision.
Glaucoma laser technologies
During his presentation, Tony Realini, MD, highlighted some of the key results from the LiGHT trial and mentioned some new laser technologies.
The LiGHT trial was a landmark trial that featured 718 patients with newly diagnosed POAG or high risk OHTN who were randomized to SLT or medications. Outcomes at 3 years included quality of life and glaucoma outcomes.
The glaucoma outcomes at 3 years saw 78% of SLT eyes at target without medications or surgery (77% needed only a single SLT). Glaucoma progression was more common in the medication group (5.8% vs. 3.8%), cataract surgery was more common in the medication group (6.9% vs. 3.7%), and glaucoma surgery was more common in the medication group (1.8% vs. 0%). He added that SLT is more cost-effective than medications. In terms of safety, there were no sight-threatening complications of SLT in any eyes, and only 1 post-SLT IOP spike requiring medications.
Dr. Realini said the 6-year results confirmed the 3-year results. In the 6-year results, 70% of SLT eyes remained medication-free and at target, and 56% of SLT eyes were still controlled with a single treatment at study entry. There was less glaucoma progression with SLT versus medications, a lower trabeculectomy rate with SLT versus medications, and a lower cataract surgery rate with SLT versus medications. There were no serious laser-related adverse events.
Discussing other glaucoma laser options, Dr. Realini briefly shared information on direct SLT (DSLT). This features direct application of laser energy to the limbal region for transscleral delivery to the TM. There is no contact lens or coupling agent, so no need for gonioscopy skills.
It also features an automated system that auto-focuses and auto-aligns, determines the circular limbal treatment area, and delivers the full treatment in only a few seconds. Gaze tracking is incorporated to ensure targeted delivery of laser energy.
Dr. Realini said that this has several potential pros over SLT—it’s easier, faster, has a better patient experience, and has significant potential in low-resource areas with high disease burden. However, he noted that the machine is currently single platform and redundant with existing systems.
Editors’ note: Dr. Realini has financial interests with Alcon, Glaukos, New World Medical, Nicox, Ocular Therapeutix, and Sight Sciences.
Barraquer Lecture
Dan Reinstein, MD, gave this year’s Barraquer Lecture, “The Jose Ignacio Barraquer Factor: Combining Scientifically Driven Clinical Practice with Pioneering Innovation, Collaboration Excellence, and Educational Leadership in Refractive Surgery.”
During his lecture Dr. Reinstein covered a number of topics in refractive surgery, taking attendees through many areas of his research over the years and going into detail on the epithelium, anatomy, ICL sizing, PRESBYOND, and SMILE.
Discussing the epithelium, Dr. Reinstein described some of his early research. He discussed other researchers he collaborated with and noted an early paper he published on corneal pachymetric topography.
He also mentioned the evolution from the lab to the Artemis to the Insight 100 (ArcScan). One of the main features of this idea was to combine an optical image with the ultrasound image, and a key to being able to do anterior segment scans is knowing where you are.
He also discussed epithelial changes in keratoconus and epithelial thickness for keratoconus screening, mentioning algorithms and models to look at this. There are a number of OCT devices to measure the epithelium, and many are FDA approved.
He also mentioned four rules for epithelial healing: fill depressions, thin over peaks, proportional to stromal change, and rate of change of curvature.
Dr. Reinstein discussed anatomy, getting deeper than just epithelial maps and looking at the anatomy of the eye. Knowing the anatomy is key to fixing complications. He shared an early therapeutic case of a patient with a complex refractive history. The patient had a highly irregular stromal surface, with a regular corneal surface. A transepithelial PTK was done for that particular patient. The stroma was removed exactly where the epithelium was thin.
Another feature of the lecture was discussing ICL sizing and safety. He said this is critical because we have phenomenal technology, but it has a problem with sizing. The key is revealing the posterior chamber, ICL sizing based on posterior chamber imaging.
Dr. Reinstein said that OCT is very good, and there are AI-powered ICL sizing formulae using anterior segment OCT.
White-to-white is step one. You can reduce the scatter of the results by using more measurements, but we won’t get to the holy grail before looking behind the iris. If you’re going to be inserting ICLs, you need an anterior segment OCT.
He said that step two of sizing is recognizing that the haptics don’t always end up in the same place. He also mentioned postop monitoring. Being able to make a map of the vault is helpful. The only way to know how close the ICL is to the crystalline lens is ultrasound.
Editors’ note: Dr. Reinstein has financial interests with ArcScan, C.S.O. Italia, and Carl Zeiss Meditec.
‘Grand Rounds: Real Cases from Around the World’
A Sunday morning session featured a variety of case presentations and panel discussion on these unique cases.
Kim Firn, MD, shared a case of a 38-year-old man who presented to general ophthalmology with 5 days of painless right eye nasal chemosis. He was given tobramycin/dexamethasone and neomycin/polymyxin B/dexamethasone for allergic reaction versus subconjunctival mass. Four days later, proptosis was noted, and an MRI was ordered. The MRI showed an enhancing, extraconal mass along the right medial rectus that was 1.1 x 0.7 x 0.7 cm. There was also lateral deviation of the optic nerve.
The patient was referred to neuro-ophthalmology. ANCA, ANA, ACE, stool O&P, CXR, MRA/MRV brain/orbit, Humphrey visual field, and OCT GCL/NFL were largely within normal limits. There was no relative afferent pupillary defect.
The patient was then referred to oculoplastics. This evaluation showed a differential diagnosis of lymphoproliferative process, cavernous hemangioma, non-specific orbital inflammation, and metastasis. A sinus approach was discussed with ENT vs. craniotomy with neurosurgery. Oral steroids for inflammation were noted on imaging, which he discontinued due to side effects. The patient also obtained a second oculoplastics opinion.
The patient presented 6 months later to the emergency department, and renal cell carcinoma was found. Meanwhile, there was a working diagnosis of presumed inflammatory autoimmune myositis. The mass grew to 1.3 x 0.8 x 1 cm, and repeat biopsy was discussed. The patient also had a lack of response to methotrexate.
The mass continued to grow to 2.4 x 1.4 x 4 cm, with encasement of the intraorbital optic nerve. Repeat orbital biopsy showed well-differentiated orbital liposarcoma. Doing a metastatic workup, a thyroid mass was found during staging (papillary thyroid carcinoma).
Interestingly, the patient had three cancers—orbital liposarcoma, renal cell carcinoma, and papillary thyroid carcinoma. His wife was also diagnosed with three primary cancers during this time. Dr. Firn noted exploration into why both the patient and his wife may have both developed these cancers, but so far, there is not a clear factor. The patient and his wife are of different ethnicities from different countries, no significant family history of cancer, and no history of smoking. Dr. Firn noted that they lived near a toxic waste site, but not within a radius where it was noted as a concern.
On literature review, there are 141 cases of primary orbital liposarcoma, Dr. Firn said, but some reports include multiple cases. She said this is the first report of primary orbital liposarcoma in association with non-syndromic multiple primary cancers.
Also during the session, Bivek Wagle, MD, shared an interesting and unusual case from Nepal. The 21-year-old female patient presented with left eye pain, redness, and blurry vision as her chief complaint. She denied a history of trauma, had never experienced anything like this in the past, eats and drinks well, and her social and family history were unremarkable. The vision in the patient’s right eye was perfectly fine, but the left eye was hand motion.
Dr. Wagle said it was hard to get a good view of the back of the eye, and fundus was difficult as well because the patient was so photophobic.
This ended up being a case of seasonal hyperacute panuveitis (SHAPU), and the issue was unique to that area of the world because the patient had embedded moth setae in the cornea. This diagnosis was based on the moth setae seen in the cornea, the rapidly progressive panuveitis, and the fact that it was monsoon season in an odd-numbered year (October 2023).
Dr. Wagle noted that this is an ocular emergency and common cause of unilateral pediatric panuveitis in Nepal. It was first reported in 1975 and occurs particularly during monsoon season in odd-numbered years. It’s unclear why older adults are not affected by this, and there is no standard treatment protocol. It’s usually treated with vitrectomy, antibiotics, and steroids, with varying success. In this case, the patient had a good outcome without vitrectomy.
Editors’ note: Dr. Firn and Dr. Wagle have no relevant financial interests.
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