Lindstrom Lecture
Marlene Moster, MD, delivered this year’s Lindstrom Lecture on “Glaucoma Surgery: Taking it to the Next Level.” When it comes to glaucoma, Dr. Moster said there are two groups: the “real deal” glaucoma, where people are going blind, and what she called glaucoma “light,” where they’re not going blind. The MIGS pipeline is very robust for mild to moderate glaucoma, she said, but for more severe patients, the options are still trabeculectomy or tubes. She highlighted four problems and new surgical interventions and innovations to improve outcomes.
The first problem she discussed was compliance, adding that many people don’t take their medicines and don’t understand their medicines. The potential solution she suggested was a new concept in drug-based delivery system that simultaneously combines cataract surgery and glaucoma medication for long duration of action (SpyGlass Pharma). Dual pads of drugs are securely placed on the haptics of a monofocal acrylic IOL, Dr. Moster said. Standard phaco is used, and dual drug pads slowly elute medication for 3 years after surgery. If approved, this new drug-based delivery system will be accessible to all ophthalmologists, including the 75% of cataract surgeons who are not currently utilizing MIGS. Enhanced drug delivery systems, such as this, will go a long way to alleviate compliance issues and improve patient outcomes.
The next problem that Dr. Moster addressed was intraocular pressure, specifically its fluctuation over time. The potential solution that could help this was a surgically placed intraocular pressure sensor (Injectsense) that is capable of 24/7 pressure readings with reliable accuracy. It is meant to be placed in the eye during a 5-minute office procedure and is self-sealing. It is rechargeable once a week and can last decades. Dr. Moster noted that there have been rare complications with minimal immune response. The physician can retrieve IOP data through the cloud to modify treatment. She mentioned a similar option that is an RFID-powered micro-sensor (Implandata) to measure IOP in mmHg located in the suprachoroidal space, inserted in combination with phaco, glaucoma surgery, or in a standalone procedure.
Next, Dr. Moster discussed goniotomy. The goal of goniotomy is to open the trabecular meshwork to expose Schlemm’s canal and collector channels and improve aqueous drainage, she said, but goniotomy opens only the anterior wall of Schlemm’s canal. There are a number of goniotomy options available, mostly focused on opening the anterior wall of Schlemm’s canal. “We do not manipulate the back wall,” Dr. Moster said. The surgical solution she shared to raise the bar and push GATT to next level is the T-Rex Duo (Iantrek), made of nitinol with firm elastic memory. This opens the inner wall and opens the back wall of Schlemm’s canal. It offers better access to the collector channels to maximize outflow with both walls open.
Lastly, Dr. Moster discussed her love/hate relationship with tube shunts, suggesting the evolution of potentially changing the material that tube shunts are made of and/or making them thinner. The first new option in development she shared was the VisiPlate (Avisi Technologies), which is ultra-thin and can bend without fracturing. It is made from nonfibrotic materials, and the multichannel design creates outflow redundancy with no hypotony. The surface area maintains the drainage space. Dr. Moster said this is made from the thinnest freestanding material in the world. She also highlighted the Gore GDI concept that is 10 times thinner than current drainage devices. The reservoir is within the plate, cells cannot grow into the reservoir, and it’s very permeable to aqueous.
Editors’ note: Dr. Moster has no financial interests related to her comments.
TOPGUN: Phaco Mavericks
While the purpose of TOPGUN is to train the U.S. Navy’s best pilots, the purpose of “TOPGUN: Phaco Mavericks,” said David Chang, MD, moderator of this session, is to have the top phaco instructors provide their best pearls in cataract surgery. The session included two teams—ASCRS and an international team LASCRS.
“We want them to present practical trade secrets that you can incorporate into the operating room next week,” he said. “This is a rapid-fire video session, extremely fast paced. That’s because we know you, the audience, feels the need … for speed!”
Here were the winners from each section:
Phaco pearls: Julie Schallhorn, MD, presented on the management of capsular rents in two scenarios. One was when there was a posterior capsule rent when she intended to place a toric IOL, and another was a case where there were dropped lens fragments. In both cases, Dr. Schallhorn employed the optic capture technique to maintain stability of the IOL.
IOL pearls: Claudio Orlich, MD, produced what panelist Kevin Miller, MD, called a video with “cinematic flare” that showcased rotation in myopic eyes. Dr. Orlich’s preferred technique to prevent rotation in these eyes is reverse optic capture.
Complex surgery pearls: Soon Phaik Chee, MD, took this category for her simple technique to remove a Soemmering’s ring. Her technique included performing an adequate anterior vitrectomy and using an IOL cartridge to keep the slit-like corneal incision rounded to enable infusion pressure to hydro-express the entire ring in a controlled manner into the cartridge.
The international team took home the overall grand prize.
Editors’ note: The speakers have no financial interests related to their comments.
Futurist lecture
Shawn DuBravac, PhD, was the guest speaker on Sunday’s Main Stage program. He shared three main thoughts.
First, he said the future requires a new operating model for how we think. He discussed the practice of ice harvesting, evolving from the late 1800s, and moving to different ways of manufacturing ice for home delivery, then to being able to create ice in the home. “It wasn’t those who were harvesting ice in the late 1800s who were manufacturing in city centers in 1920s, and it wasn’t those people bringing ice to our homes in the 1940s,” he said. “With each technological shift, a new structure rose to the top to dominate the market.” Entire industries were replaced by new ones. “That’s the great challenge for all of us is how do we make the leap when technology shifts underneath us,” he said.
His next thought was that we are moving to the next big transformation, moving from digitization to datafication. He shared several examples of companies making this move, including Coca-Cola’s freestyle machines that allow users to mix and match flavors. These machines are also sending data to Coca-Cola, allowing them to know what’s being poured, he said.
Amazon is also thinking about moving from digitization to datafication, Dr. DuBravac said, giving the example of an Amazon store that allows you to scan clothing you’re interested in while browsing for it to be delivered to a dressing room in your size to try on.
He further discussed AI-generated photos and synthetic copies of people, as well as technology on Zoom to simulate eye contact.
Don’t just think of first order effects with this new technology, Dr. DuBravac said; it’s the second order effects that start to kick in when we change the way we compute and change the way we interact with computers. He noted that, “ChatGPT isn’t going to replace anyone in this room.” He did say “it’s going to influence the people we treat.” He added that AI is becoming a piece of the dynamic. I think AI and the ones who understand how to use it will unleash what the future holds, Dr. DuBravac said.
His last thought was that the future requires a new approach. He shared the story of a world chess champion Garry Kasparov, who was beaten by a computer, and the idea that if the best chess player in the world gets beat by a computer, that’s one more thing that computers do better. However, Dr. DuBravac noted changes in perception to be open to new types of chess and ways to combine both human and computer programs when playing.
‘Myths and Misconceptions in Refractive Surgery’
In a symposium highlighting “Myths and Misconceptions in Refractive Surgery” on Sunday morning, Steven Schallhorn, MD, discussed whether pupil size matters in refractive surgery. How did we come to believe that a large pupil was strongly correlated to quality of vision symptoms after LVC?
We know patients can have quality of vision problems after laser vision correction, Dr. Schallhorn said, especially with older ablation profiles and smaller optical zones. “We know that increasing pupil size increases aberrations,” he said. “We know that pharmacologic constricting of the pupil often improves quality of vision.” He also said it’s known that optical modeling and intuition says that pupil size should matter, and there is anecdotal experience in support of this from passionate patients, surgeons, and lawyers, he said.
However, Dr. Schallhorn said, if you look at clinical studies that have evaluated this, there are 14 studies with thousands of patients that show that pupil size does not matter. There are only two studies that show that pupil size does matter. Dr. Schallhorn said that one was with an old laser with a small optical zone size and small number of patients, and in the other, there was a relationship with one quality of vision metric (starburst) but not glare/halo.
So, why can’t pupil size matter? Dr. Schallhorn said one issue is the Stiles-Crawford effect. The directional sensitivity of the retina is an adaptive mechanism that reduces the visual effect of aberrated light from larger pupils, Dr. Schallhorn said.
Dr. Schallhorn shared another clinical study with a sample size of 10,000 patients that looked at LASIK dissatisfaction vs. pupil and found no difference in pupil size. There was also no difference in glare/halo and pupil size and no difference in night driving and pupil size.
The bottom line, Dr. Schallhorn said, is that pupil size doesn’t matter for quality of vision after LASIK, based on literature and studies. When asked by a panel about how to educate patients on this topic, it’s important to tell patients that they can expect to see glare and halo and starbursts in the early postop period while the eye is healing.
Editors’ note: Dr. Schallhorn has financial interests with Carl Zeiss Meditec and Optical Express.
Making the uncomfortable comfortable
The first part of a two-part symposium, “Making the Uncomfortable Comfortable: Strategies for Managing Complex Cases and Advanced Technology IOLs,” included the topics of getting your patient to target, improving the patient experience at all stages of the cataract journey, and presentations on mixing and matching, what to do in post-refractive surgery eyes, adjustability, small aperture, pharmacologic presbyopia correction, and more.
Warren Hill, MD, shared his 6 steps for getting to target.
- Optimize the ocular surface for 2 weeks prior to biometry. This makes a huge difference as far as outcomes, Dr. Hill said. His protocol for all cataract patients includes use of compresses twice daily, lid scrubs, frequent high-quality tears.
- Follow a set protocol with your staff and then use validation criteria. Dr. Hill said to make sure your staff knows when they need to delete and repeat, and if not, have them ask you.
- Use IOL power calculation methods from this century. Dr. Hill said we have some new tools right now, including the ESCRS IOL Calculator, which allows you to look at a number of formulas.
- Standardized, accurate endpoint refractions. Dr. Hill said one wrong click with the phoropter can have an impact. Accurate refractions are important for tracking outcomes and optimizing lens constants.
- Track outcomes. Doing cataract surgery without outcomes is like going to sea without a chart and a rudder, Dr. Hill said, mentioning the IOL Calculation Analyzer, a free offering from ASCRS.
- Optimize lens constants. Dr. Hill said this can be difficult if you don’t have the right software, but there are a number of courses that can help you have this done.
Dr. Hill said the standard right now is 90% within 0.5 D of target. He said this is completely doable following his steps.
John Berdahl, MD, offered his advice on improving the patient experience from a counselling standpoint throughout the patient journey. Currently, he said, patients are given a lot of information up front, but what they need to know are the risks, benefits, and alternatives, high-quality surgery, to see well, and to know the cost. What patients want, Dr. Berdahl continued, is to know that you care, your time, to not wait, to get on with their life, to get a good value, no pain, and to know what you would do if it were your eye.
Dr. Berdahl said the physician doesn’t spend enough time with the patient to give them the experience they deserve. He showed a series of short videos that his practice uses to educate the patients at each stage of their cataract journey, delivering them to the patient at just the right time throughout. These include everything from a presurgery video to a morning after surgery video to videos for 1 week, 1 month, 3 months, 100 days, and 6 months after surgery.
These videos, Dr. Berdahl said, not only educate the patient but cause them to feel like they know their doctor. They get that time with you, he said.
Editors’ note: The speakers have financial interests with several ophthalmic companies.
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