- Refractive targeting and RLE
- IOL selection
- ‘Glaucoma Fellowship Directors’ Survival Guide—Surgical Pearls We Teach Our Fellows’
- Refractive Surgery Rounds
Refractive targeting and RLE
Kicking off Refractive Day at AAO programming, Luke Rebenitsch, MD, presented on refractive targeting and patient satisfaction in refractive lens exchange.
He noted the many lens options available and the increased patient expectations, as well as the importance of intermediate vision. You have to be willing to do LVC enhancements and IOL exchanges, he added.
So, is there a “best” lens? Dr. Rebenitsch said there is no perfect lens.
He described a recent study he did that was a retrospective cohort study comparing three IOL strategies (with 50 patients in each group): DFR00V/DXR00V (Johnson & Johnson Vision) mix and match (FX), bilateral DRN00V (RR), and DRN00V/DXR00V mix and match (RX).
There was high overall satisfaction among all groups in the study. UNVA was superior in the FX and RR combination at 3 months and at final measurement, and bilateral uncorrected distance vision was excellent in all groups. Refractive results were similar among the three groups.
Dr. Rebenitsch also noted that some IOL exchanges needed to be performed, almost all due to intermediate vision or distance contrast complaints. We’re seeing the same thing with most recent additions to the market, he added.
How do you troubleshoot the 20/unhappy patient? Dr. Rebenitsch said to use LVC/LRI to hit the refractive target. You also must look at the ocular surface, he said, noting that he’s finding Demodex in many patients. Media opacity can be important as well, and floaters can sometimes be more noticeable or pronounced. Finally, he mentioned neuroadaptation, adding that time takes care of many issues, and he usually recommends giving patients 3–6 months to adapt.
Every lens has a strength and weakness, and every defocus curve is different, he said. Even 0.25 D can make a difference. Some lenses do better slightly hyperopic or myopic, so it’s important to know how the lens you’re going to be using performs.
Choosing the right lens for the right person is of paramount importance, Dr. Rebenitsch said. Have a plan to troubleshoot the 20/unhappy patients, and mixing and matching lenses is a strategy that may improve patient satisfaction given the demand for visual quality and intermediate vision.
Editors’ note: Dr. Rebenitsch has financial interests with Ace Vision Group, Bausch + Lomb, Johnson & Johnson Vision, RxSight, STAAR Surgical, and Zeiss.
IOL selection
Also on the Refractive Day program, Neda Shamie, MD, discussed IOL selection in eyes with prior corneal refractive surgery.
Dr. Shamie said that having this surgery previously with good results can lead to high patient expectations. These patients also have modified corneal contour, which can lead to inaccurate IOL calculations, and they often have ocular surface issues. The goal is to achieve the highest chance of reaching the refractive goal and getting patients optimized vision.
Sharing data on how several formulas can help with target refraction, Dr. Shamie said the best formula achieves 72–73% within plus or minus 0.5 D.
Presbyopia-correcting IOLs have evolved over the years, Dr. Shamie said, but the best options with these lenses come with the refractive target being achieved. If the refractive outcome is off target, the patient might need LVC enhancements; if the eye already had LASIK, this might not be ideal.
What if you could shift the refractive adjustment from preop to postop? This is what the LAL (RxSight) allows, Dr. Shamie said. It gives the opportunity to make the adjustment and fine-tune the vision postop. She shared recent data from a study from Julie Schallhorn, MD, published in the October issue of the Journal of Cataract & Refractive Surgery, showing that refractive outcomes are unaffected by corneal refractive surgery with the LAL. The study included more than 1,000 patients from 126 clinical sites in the U.S., and results showed a high degree of precision in eyes with and without prior corneal refractive surgery. Those with corneal refractive surgery had similar results as those without.
Dr. Shamie concluded her presentation with several pearls for post-refractive eyes. First, she stressed the importance of optimizing the ocular surface, regardless of which IOL is chosen.
Non-diffractive EDOF and trifocal lenses can be used in select eyes. The LAL offers the highest chance of reaching the refractive goal and vision potential. You can continue to optimize the ocular surface through the light adjustments. She recommended choosing the LAL and not the LAL+ for these patients and to verify stable refraction before initiating LDD treatments and between treatments. Generally, she said to start treatments at about 3–4 weeks and separate them by 1–2 weeks.
Editors’ note: Dr. Shamie has financial interests with Alcon, Bausch + Lomb, Johnson & Johnson Vision, LENSAR, and RxSight.
‘Glaucoma Fellowship Directors’ Survival Guide—Surgical Pearls We Teach Our Fellows’
In an AAO Glaucoma Day session moderated by Shivani Kamat, MD, and Mary Qiu, MD, presenters offered pearls on a number of different topics.
David Fleischman, MD, focused his presentation on his Limbix technique for trabeculectomy. First introducing the types of trabeculectomy, he noted the importance of being able to perform a trab.
Options are a fornix-based approach, where the conjunctiva is secured at the limbus, or a limbus-based approach, where the conjunctiva and Tenon’s capsule are closed separately or in a single layer. There are advantages and disadvantages to each, he said.
For a fornix-based trab, the pros are that it’s easier, faster, no assistant is needed, and the bleb is posterior and diffuse. However, a con is that it’s harder to achieve water-tight closure.
For a limbus-based trab, a pro is that the closure technique is conj-to-conj, but it’s also harder to perform solo, and bleb architecture is anterior and focal.
Dr. Fleischman described the Limbix technique, which provides intentional control of the location of the Tenon’s wound edge and its subsequent scar formation.
He shared results in his first 10 patients (11 eyes). While he said it worked well, it’s not perfect. There was some wound leak, though Dr. Fleischman noted that pressure outcomes were pretty good. He has done 40+ of these and said it’s his current go-to trab procedure.
Pros of the Limbix technique are that bleb architecture is similar to fornix-based trabeculectomy; it’s faster than a limbus-based trabeculectomy, with no need for an assistant, and there is less wound leak than with his fornix-based technique. Cons of this technique are that it takes longer and is more complicated than Dr. Fleischman’s fornix-based technique, and there is more early wound leak than with his limbus-based technique.
Also in the session, Brian Francis, MD, discussed tube revision pearls. He first discussed standard tube erosion, an erosion of the tube occurring between the limbus and the plate. A fornix-based dissection can be used with posterior dissection around the tube and over the plate. He said to lyse the adhesions between the capsule and Tenon’s.
Then Dr. Francis discussed complex tube shunt exposure, which could be from exposure problems or conjunctival scarring. You should be able to do a limbus-based dissection, he said, adding that scleral dissection can be used (dissect in the scleral plane and leave the conjunctiva intact), as well as an autologous patch graft. He also recommended a two-layer running closure.
Finally, he highlighted a glaucoma tube shunt plate exposure. The typical teaching is to remove the tube shunt. The key is wide undermining around the exposed area. Dissect underneath the exposed plate and remove the epithelium from underneath the plate, he said, adding that he likes to use a pericardium patch graft with wide margins.
Editors’ note: Dr. Fleischman has no relevant financial disclosures. Dr. Francis has financial interests with AbbVie, Alcon, Bausch + Lomb, Beaver-Visitec, Iridex, MicroSurgical Technology, New World Medical, Thea, and Virtual Vision Health.
Refractive Surgery Rounds
In a Friday afternoon refractive session, presenters shared a variety of cases. Nicole Fram, MD, shared a case of a piggyback ICL with a surprise. Her 58-year-old patient had a past history of myopic LASIK with a refractive miss. She also had significant Soemmering’s ring and open posterior capsule and had become intolerant to contact lenses. The corneal topography showed a decentered ablation, with a fair amount of irregular astigmatism, and the cell count appeared normal.
Dr. Fram planned to do an off-label piggyback ICL. When she started the case, she was feeling great initially putting in the lens. She started to see some shadowing and saw something move, only to have vitreous coming around the zonule. Dr. Fram closed her main incision and asked for a vitrector and did a sub-Tenon’s block. She amputated the vitreous posteriorly for a more controlled environment. Some vitreous was caught in the incision, but it was amputated, and you’re free to get it out once it’s amputated, she said.
Dr. Fram was able to finish her case nicely but said this was still a stressful moment and could have ended differently if she hadn’t had the skillset to do a pars plana vitrectomy.
Editors’ note: Dr. Fram has financial interests with AbbVie, Alcon, Aurion, Beaver-Visitec, Dompé, Glaukos, Johnson & Johnson Vision, MicroSurgical Technology, Ocular Therapeutix, Orasis, Tarsus, and Zeiss.
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