- ‘Craziest Video Cases’ part I
- Pearls in refractive cataract surgery
- Review of presbyopia-correcting IOLs
- Presbyopia treatments
- ‘Craziest Video Cases’ part II
‘Craziest Video Cases’ part I
“This is always the most exciting part of a meeting,” Manjool Shah, MD, moderator of the “Craziest Video Cases” session on Saturday afternoon said, before handing it off to Cathleen McCabe, MD, for the first presentation in which she discussed a case of extreme kyphosis.
The patient in this case was facing the floor when standing. Once in the OR, he was sitting back as far as he could, and his head and neck were significantly raised from the bed. Dr. McCabe shared how she adjusted her microscope oculars to look straight forward instead of down and operated with her arms held straight in front of her. Her staff, she said, had to hold the patient’s head up and hold the lid speculum in place.
She said she was able to start her incisions and capsulorhexis normally with the rest of the case going “remarkably well.” She joked that all of her pieces were coming forward thanks to gravity working in her favor. She was, however, concerned with the patient’s use of postop drops and injected triamcinolone and moxifloxacin. For steroids, she recommended a device called Simply Touch Eye Drop Applicator, which holds a drop on it that is then held against the conjunctiva.
The patient later came in for his second eye, which was actually more difficult due to his head being more tilted on that side and “because I’m right handed,” Dr. McCabe said.
“Now I have to hyperflex my neck and to look down in the microscope,” Dr. McCabe, who operated again with her arms extended, said. She said she didn’t have enough space between her arms and the patient’s chest. Each time he breathed, he moved the microscope, requiring Dr. McCabe to refocus and recenter. She also had to have the patient redraped several times, and they took a few breaks throughout the case.
She said she used a pre-chop technique because it was one-handed and successfully removed half of the cataract. The second half did not come out as easily. Eventually, Dr. McCabe said, the capsule broke. Nothing was coming up posteriorly, and Dr. McCabe used a lens loop to remove the rest of the nucleus. The bag was saved with a largely intact anterior capsulorhexis. She did an anterior vitrectomy and got the lens where she wanted it.
When she saw the patient back later to remove sutures, there was no vitreous in the anterior chamber, the pupil was round, and the IOL was where it needed to be.
“This is an advertisement for a heads-up microscope,” Dr. McCabe said, noting that her new ASC will have a heads-up microscope that she plans on using for another patient with extreme kyphosis soon.
Other video presentations in the session included addressing a scleral-fixated IOL with GORE-TEX that was repeatedly exposed, a monocular patient who had a Yamane technique performed under an “open sky” followed by a corneal transplant, a complicated intumescent cataract case, and more.
Editors’ note: The physicians have financial interests with various ophthalmic companies.
Pearls in refractive cataract surgery
Sunday morning reviewed pearls for various aspects of refractive cataract surgery, from patient counselling all the way through residual refractive errors.
Beeran Meghpara, MD, said he considers patient selection and counselling “one of the most important things when it comes to refractive cataract surgery. His pearls included:
- Perform topography and OCT: Even though you might not always be able to bill for it, Dr. Meghpara said, it’s worth being able to pick up on subtle pathology that you may have missed on exam. Identifying subtle EBMD via Placido rings (and then treating it), he noted, can affect a patient’s astigmatism management. OCT can identify macular pathology that could impact whether you might recommend a presbyopia-correcting IOL. Topography helps identify regular vs. irregular astigmatism, Dr. Meghpara said.
- Understand all the IOLs: Dr. Meghpara said you need to understand what your IOLs do and their limitations. Understanding what a defocus curve is helps.
- Be aware of low myopes: These patients have the ability prior to cataract surgery to see fairly well across a variety of distances, Dr. Meghpara said. These patients’ near vision can be affected depending on IOL selection, so Dr. Meghpara said he has the patient repeat back what they should expect in terms of their vision postop.
- Channel your inner psychiatrist: Questionnaires help reveal various personality traits about a patient that can impact IOL selection.
- Address the IOL exchange: The possibility of IOL exchange, Dr. Meghpara said, should be discussed with the patient preoperatively. He also said that surgeons offering refractive cataract surgery should be able to exchange or have a reliable referral source who knows how to do it. Dr. Meghpara also said to resist the urge to YAG because it can make IOL exchange more difficult if needed later.
Mitchell Weikert, MD, shared his pearls for biometry and IOL calculations, which he said are the cornerstones of refractive cataract surgery.
- Know your formulas and their limitations: The vast majority of formulas are still based on geometric options, Dr. Weikert said, and there are a lot of assumptions and simplifications that go into these formulas. Every formula, he added, has a different way of approaching effective lens positioning.
- Check your metrics. Do they make sense? Axial length and keratometry are incorporated into all formulas and other variables need to be measured accurately as well. Dr. Weikert gave his specific pearls for checking whether axial length measurements and keratometry measurements make sense.
- Know when to expect the unexpected: There are four common clinical scenarios when IOL calculations may be off: long eyes, short eyes, keratoconic eyes, and post-corneal refractive surgery. For long eyes, Dr. Weikert said, the Barrett Universal 2, Wang-Koch, and Kane work well. For short eyes, “nothing is great,” he said, noting that Cook K6, Kane, and Hill-RBF 3.0 did well, but getting within 0.5 D was still about 70%. For keratoconus, the Barrett KC, Kane-KC, and SRK-T work well, Dr. Weikert said. For post-refractive eyes, Dr. Weikert mentioned the ASCRS post-refractive calculator and the Barrett True-K TK.
- Take multiple measurements: For astigmatism, Dr. Weikert says he recommends taking at least three measurements.
- Explain it to patients: Explaining all of this to the patient “takes mere seconds,” Dr. Weikert said. He said he’ll first briefly explain eye anatomy and say that the main two measurements that inform IOL calculations are length of the eye and focusing power. He said that these and other measurements help predict where the lens will end up in the eye, and while the formulas do a good job, there is always variability, and surgeries like LASIK/PRK and certain anatomy can increase this variability.
Douglas Koch, MD, offered his pearls for astigmatism.
- Know you can’t always get what you want: There is too much variability in measurements, alignment, surgically induced astigmatism, and the corneal surface.
- Evaluate and treat the ocular surface: This is the one thing that we have the most control of in IOL calculations in terms of trying to reduce variability, Dr. Koch said. He said he has every patient use artificial tears, warm compresses, and lid scrubs for 2 weeks prior to measurements (selling these materials within the clinic).
- Measure three times, preferably on different days: Dr. Koch said that he uses two biometers, but he noted that you could use the same biometer on different days or the same one at different times within the same day. He also discussed the posterior cornea, noting that research has shown that measuring it is more accurate than making assumptions but just a little. “The real thing here is the posterior cornea is not the whole story; formulas based on total corneal astigmatism alone will miss other factors.”
- Manual marking can be very accurate: Dr. Koch noted research that found manual marking based on vessels and anatomical characteristics was just as precise as an automated method.
- Is there a role for relaxing incisions? “I like them for small amounts of astigmatism,” Dr. Koch said.
- Leave a small amount of WTR astigmatism: Dr. Koch said to target the first step on the WTR side and to beware of formulas that recommend the lowest amount of astigmatism regardless of axis.
Editors’ note: The physicians have financial interests with various ophthalmic companies.
Review of presbyopia-correcting IOLs
This review of presbyopia-correcting IOLs covered how to talk about these options, points on patient selection, and how to manage the unhappy patient.
Daniel Chang, MD, reviewed the available technologies, saying that the nomenclature when talking about presbyopia-correcting IOLs can be “somewhat arbitrary and confusing.” He has opted instead to start using the term “range of vision.” He said he discusses these advanced technology IOLs as providing either a full range of vision or an extended range of vision, depending on their ability.
Cathleen McCabe, MD, shared her points on patient selection for a presbyopia-correcting IOL. Her first tips for success were to listen to the patient, set realistic expectations, obtain quality biometry, treat OSD preoperatively (making sure that treatment is sustainable), and make a strong recommendation to the patient. Candidates for a presbyopia-correcting IOL are those who wish to be glasses-free, those who are tolerant of the possibility of glare and halo at night, and those who understand the compromise of these lens options, she said. Dr. McCabe said she uses a lot of photos and animations to help explain these elements to her patients.
A good candidate should have healthy eyes and the ability to maintain a healthy ocular surface, Dr. McCabe reiterated, with both eyes having good visual potential, she added. Patients to avoid for multifocal or trifocal IOLs include patients with unhealthy eyes, monocular patients, those with early signs of progressive disease, those who have concerns about glare and halo, patients with significant dry eye, and patients with exacting or unrealistic expectations.
Zachary Zavodni, MD, presented on management of the unhappy patient. Reasons for an unhappy patient postop (after healing is complete), Dr. Zavodni said, include refractive error, anisometropia, capsular bag striae, other pathologies (dry eye, floaters, ABMD, Fuchs, retina issues, glaucoma), poor preop education (misalignment of expectations), and lens type/design impacting image quality (dysphotopsia).
Your number one goal with these patients, Dr. Zavodni continued, is to gain their trust. To do this, listen, empathize, and make yourself available to them. He also said that problem solving out loud with them can be helpful.
If the patient is close to the “finish line,” Dr. Zavodni advised that they might need more time to neuroadapt, their ocular surface might need treatment, or they could need more time for capsular folds to stretch out. If the refractive error is the chief complaint, Dr. Zavodni said he’ll do an excimer enhancement for myopic corrections of 2 D or less or in eyes that might present difficulty in the OR (capsular fibrosis, post-vitrectomy, an open capsule, etc.). A trip back to the OR is necessary for rotations, exchange, or vitrectomy to address floaters, he said.
Editors’ note: The physicians have financial interests with various ophthalmic companies.
Presbyopia treatments
During Sunday’s program, Douglas Koch, MD, moderated a session on presbyopia treatments, which included a number of case studies. Faculty during the session included Daniel Chang, MD, Marjan Farid, MD, Kourtney Houser, MD, and Zachary Zavodni, MD.
Dr. Farid shared the case of a young presbyope, a 38-year-old woman who said she had always had perfect vision until the last couple months and “can’t see anymore.” The main issue the patient complained of was that she couldn’t see her cell phone. The patient had 20/25 UCDVA in both eyes, had a normal exam, and was a little hyperopic.
For this patient, Dr. Zavodni said he would consider non-surgical options. He suggested trying Vuity (pilocarpine, Allergan) as a first option. Dr. Zavodni anticipated that things might get worse for this patient as time goes by, so he suggested introducing the concept of surgery, though he said he wouldn’t immediately push it.
Dr. Koch said he might introduce the option of hyperopic LASIK in order to buy some time for the patient.
Dr. Farid added that there will be additional future options with more products like Vuity. This market will help us give a patient like this more options, she said. But once you get to higher hyperopia, it’s reasonable to consider laser vision correction, she said.
Dr. Houser discussed the presbyope with ocular surface disease. Her case was a 60-year-old female who had glare and trouble with night driving. She had been previously scheduled for cataract surgery elsewhere before moving to the area and was motivated for glasses independence. The patient had significant cataracts and had peripheral Salzmann’s nodules. Dr. Houser noted that the topography was a little irregular in the center 3 mm.
She proceeded by doing a superficial keratectomy with PTK in the right eye, and a superficial keratectomy in the left eye. Then she waited 8 weeks and reevaluated the patient. The patient corrected to 20/20 after the Salzmann’s nodules came off, but she still had glare at night. Dr. Houser noted that the topography looked a lot better, but there were still some concerns in the left eye.
She asked the other panelists which IOL they would choose for this patient who was highly motivated to be out of glasses.
Dr. Farid suggested that she might try a Synergy toric (Johnson & Johnson Vision). She noted that she had a similar case, and thinking back, she said she might lean toward an EDOF because you have a little more wiggle room against future irregularities that can redevelop.
Dr. Chang said he would have a conversation with the patient about getting out of glasses. If the patient didn’t care as much, he might leave the Salzmann’s nodules and just do a monofocal IOL.
Dr. Zavodni noted that he might even be hesitant to do an EDOF lens because the astigmatism in the left eye still did not appear to be regular.
Dr. Farid added that it might be interesting to see how the IC-8/Apthera (AcuFocus) works in the left eye, which might help with the slight irregularity. She added that a monofocal could potentially be used in the right eye.
Dr. Houser said she ultimately was also hesitant in the left eye. She ended up using a toric in the right eye because it was regular and a non-toric Vivity (Alcon) in the left eye.
The patient ended up happy at 20/20 and didn’t have a lot of manifest refractive error in irregular astigmatism eye.
Editors’ note: The physicians have financial interests with various ophthalmic companies.
‘Craziest Video Cases’ part II
In a continuation of Saturday afternoon’s session, Sunday’s program featured part II of the craziest video cases session. Mitchell Weikert, MD, moderated the session, with David Crandall, MD, Sumitra Khandelwal, MD, William Trattler, MD, and Douglas Koch, MD.
Dr. Koch shared a case of a patient who had a toric lens implanted several years ago that had dislocated. It was a 2 D toric lens and a CTR. Dr. Koch was working on pulling the bag back into position and was using 9-0 Prolene sutures to dock the CTR. He was almost done the case, but the lens was still a bit loose, and as he was trying to fix it, there was a complication. The patient had a dead bag, so there was no cortical material, and the CTR had caused a tear. Dr. Koch then had to go through the optic haptic junction, but the patient ended up 20/25. He noted that “if you see an eye that has an IOL that you need to exchange, and there’s no cortical material, that is a dead bag.” In these cases, you need to be prepared for an alternate mode of fixating the IOL, he said.
Dr. Trattler discussed issues that can occur with pterygium surgery. He noted that he uses a modified Anduze technique. In the video he shared, the case started out as a straightforward surgery. He noted that he will often cut across the pterygium so he has two parts to work on, the cornea part and the rest of the pterygium. As he got further into the case and was dissecting the scar off, he began to notice something out of the ordinary. The patient had a LASIK flap that had been pulled up as the pterygium was being taken off. Dr. Trattler ended up cutting off the scar part of the cornea and leaving the flap. He noted that if there was further issue, he could address this later, but he didn’t want to cause more problems. One of his concerns was for epithelial ingrowth, which he didn’t have in this case, but there was some regular astigmatism. He noted that when you take off the LASIK flap, there is also a chance of haze developing underneath.
Editors’ note: The physicians have financial interests with various ophthalmic companies.
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