‘Spotlight on Cataract’
The Monday “Spotlight on Cataract” session was chaired by David F. Chang, MD, and Surendra Basti, MD, and featured rapid-fire presentations, with experts offering their top five pearls on a number of topics in managing phaco and refractive IOL challenges. It was also the 25th year of this session, and Dr. Basti shared a video to celebrate this and acknowledge Dr. Chang for his role in the session.
Inder Paul Singh, MD, highlighted the importance of surgeon ergonomics, first sharing his personal experience to explain why he’s passionate about this topic. He had spinal stenosis in 2018. Even now he still has headaches and gets stiff after surgery.
For every inch that the head is held forward in poor posture, an additional 10 pounds of weight is felt on the cervical spine, he said, adding that elevated, angled surgical foot pedals allow for a more natural position for the leg.
Dr. Singh offered his five pearls on this topic. First, in the OR, bring the bed closer to the chair, raise the bed higher, move yourself forward in the seat, with shoulders out, bend the knee slightly, and keep the pedal forward.
He also suggested utilizing heads-up technology. Positioning your body is key, even when you do heads-up. Decouple yourself from the oculars.
He said it’s important not to forget the office and offered considerations for when you’re at the slit lamp. Raise the patient to your height, bring the lamp closer to the edge, and extend the oculars.
Dr. Singh also mentioned that when using elbow support, you can bring the elbow to the level of the shoulder and move the elbow to the side to improve positioning. Lastly, he stressed the importance of doing exercises throughout the day, particularly noting the chin tuck exercise.
Lisa Nijm, MD, JD, presented on risk management with premium IOLs. Her first pearl was to educate, recommend, don’t sell. As a surgeon, the lens is a medical recommendation, and it’s yours. You explain the cost, risks, and alternatives, not a counselor.
Her second pearl was to pick the eye before you pick the lens. Ocular surface, macula, cornea, and fields decide who is a multifocal candidate. Examine every co-managed referral yourself, she said.
Her next pearl was that time-out is your best witness. As a surgeon, it’s important to confirm measurements before the plan leaves the office. At time-out, check the lens type and power against the chart and the patient.
She also said you need to “earn the second eye.” Finally, she added that the chart is your testimony. Complications happen, so it’s important to diagnose early, refer early, and tell the patient early.
Nicole Fram, MD, gave this year’s Kelman Lecture on the topic of “Courage Before Confidence: How Surgeons Are Made.” Dr. Fram shared her “roadmap” to how surgeons are made.
The first stop is curiosity and competence. How do we effectively learn as surgeons? When thinking about training, Dr. Fram noted the Halsted model of: “See one. Do one. Teach one.” Noting that you can learn through audio, visual, or tactile methods, Dr. Fram suggested updating this to “See one. Sim one. Do one. Teach one.”
Determination and perseverance was Dr. Fram’s next stop on her roadmap. How do I gain experience when I have no experience? Being an early adopter is one of the best examples of this. Dr. Fram highlighted the evolution of the intrascleral haptic fixation technique, noting that Shin Yamane, MD, PhD, won the ASCRS Film Festival in 2016 for his technique in this area.
The next stop on her roadmap was empathy. How do I remember that every complication has a person attached to it? Dr. Fram highlighted negative dysphotopsia as a problem that can plague patients, and how she, along with Sam Masket, MD, and their group, sought to address this problem.
Resilience, the next stop, was something she said can take you from good to great. What do I do when the operation doesn’t go as planned? She shared a case where she had to pivot from Plan A to Plan B. Though she felt like a bit of a failure that the original plan didn’t work, she knew she had the skills to complete the surgery. The key to getting through this was to compartmentalize.
The next stop on her roadmap was innovation and creativity. What happens when we stop accepting the way things are? She particularly noted femtosecond laser technology. A controversial topic right now is robotics. Is it needed in cataract, retina, and other surgeries? When you have an urge to reject something new, think about what hasn’t been developed yet. We should challenge ourselves to always be creative and innovative, she said.
Humility was another stop she made on her roadmap. Humility before the case is having a Plan B and C. During the case, it’s knowing that the case isn’t going as planned and knowing to stop or pivot, and after the case, it’s about sharing your mistakes and evolving.
Stewardship and service was the final stop, and Dr. Fram noted the Masket Foundation and its fellowship.
To the next generation, she said to have the courage to begin; the confidence will come later. Struggle is part of the journey, and remember to dream about what does not yet exist. Tune out the noise, and get creative, Dr. Fram said.
Editors’ note: Dr. Singh has financial interests with AbbVie, Bausch + Lomb, BVI, Elios, Ellex, Glaukos, iSTAR Medical, Ivantis, New World Medical, Sight Sciences, and Tarsus. Dr. Nijm has no relevant financial disclosures. Dr. Fram has financial disclosures with AbbVie, Alcon, Aurion, BVI, Glaukos, Johnson & Johnson Vision, MicroSurgical Technology, Ocular Therapeutix, Orasis, Tarsus, and Zeiss.
Advancements in lamellar keratoplasty
A Sunday afternoon symposium highlighted topics relating to advancements in lamellar keratoplasty.
Clara Chan, MD, presented on complications and management with lamellar keratoplasty. She offered four take-home points to kick off her presentation. DMEK is great until it isn’t, so try to stay calm. For DMAK, you can use your DMEK preparation skills. For lamellar keratoplasty, she recommended having cyanoacrylate glue on standby. And for DALK, have a rescue strategy in mind; it’s worth the effort.
She also shared several DMEK tips. Construct wounds carefully, and avoid inadvertent enlarging of an old wound. Avoid “burping” the posterior wound lip when exiting with the injector. Bevel down, but don’t lift up. She said it’s ok to re-stain, and visualization is key. Ensure there is low pressure in the anterior chamber (AC) during insertion. Dr. Chan added that you may need an AC maintainer if the AC is too shallow. Keep the AC deep as long as possible to avoid blood and fibrin. Air tamponade for blood in the AC is very effective, she said, adding that you can deepen the AC to help reposition an upside down DMEK graft.
Vincenzo Sarnicola, MD, gave a lecture on deep anterior lamellar keratoplasty (DALK), noting that DALK is not just for keratoconus anymore. When speaking about DALK, everyone thinks about big bubble for keratoconus, Dr. Sarnicola said, adding that this is the standard technique now.
He also discussed the peeling off technique, which was the first technique described for DALK, but it didn’t become very popular. He shared his peeling off spiral technique, which involved finding the deepest plane by peeling off the tissue.
DALK is indicated for any stromal disease, and PK should be avoided when the endothelium is still functioning, he said.
Editors’ note: Dr. Chan has financial disclosures with AbbVie, adMare BioInnovations, Apotex, Aurion, Bausch + Lomb, Claris Bio, CorNeat, Johnson & Johnson Vision, Kala Pharmaceuticals, Labtician Ophthalmics, Sun Ophthalmics, Thea, Valeo, and Vital Tears. Dr. Sarnicola has no relevant financial disclosures.
Cataract complications and management
The Ophthalmic Premier League session on Sunday afternoon featured presenters sharing video cases of cataract complications and their management.
Sam Masket, MD, presented on negative dysphotopsia (ND). He first noted that it’s important to recognize that this patient is not crazy. From prior investigations, Dr. Masket said the common pathway for ND is any “in the bag” IOL with the (nasal) anterior capsulotomy edge overlying the optics. ND is prevented, relieved, or improved when the IOL optic edge overlies the (nasal) anterior capsulotomy with reverse optic capture or with a capsulotomy fixated IOL. Examples of anterior capsulotomy fixated IOLs include the Morcher Bag-in-the-Lens (BIL), the FEMTIS (Teleon Surgical), and the Morcher 90S, but Dr. Masket said these are not approved for use in the U.S.
He shared a study by him and Nicole Fram, MD, from 8 years ago, noting the use and success of primary reverse optic capture and secondary reverse optic capture in these patients.
For primary reverse optic capture, Dr. Masket recommends a 3-piece IOL with loops at 12:00 and 6:00. Meanwhile, he cautioned that secondary reverse optic capture is not advisable with all single piece acrylic IOLs if they are too high powered or the haptic optic junction too thick.
The way to help the ND patient is by reverse optic capture, primarily or secondarily, Dr. Masket said.
Editors’ note: Dr. Masket has financial interests with CAPSULaser, Haag-Streit, and Morcher.
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