March 2014




Reporting live from ASCRS•ASOA Winter Update 2014 in Fajardo, Puerto Rico


Reporting live from the 2014 ASCRS•ASOA Winter Update Fajardo, Puerto Rico


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W. Barry Lee, MD, explains how to recognize signs of contact lens-associated limbal stem cell deficiency and how to treat this serious complication.

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Kerry D. Solomon, MD, discusses an integrated system for operative planning and intraoperative assistance for toric IOL implantation.

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Vincent P. de Luise, MD, discusses ocular surface disease and phacoemulsification.

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David F. Chang, MD, describes advanced OVD techniques for the management of radial tears, zonular dialysis, and posterior capsular rupture.

Friday, Feb. 14

ASCRS•ASOA Winter Update 2014 in Puerto Rico opened Friday with a panel of experts discussing challenging cases and complications management during a morning video symposium.

Brock K. Bakewell, MD, Tucson, Ariz., shared the case of a 72-year-old patient who was hit in the left cheek with a golf ball in 2001. At the time, her traumatic cataract with five clock hours of zonular dehiscence and traumatic mydriasis to 9 mm was repaired with slow-motion phaco with placement of a CTR and a three-piece PCIOL and two Morcher 50 D artificial iris devices. In December of last year, she presented with a dramatic change in visual acuity. "An exam showed almost complete dislocation of the IOL and artificial iris," Dr. Bakewell said. The case illustrates that a late dislocation of a PCIOL/ artificial iris can occur because of progressive zonulopathy, even with a CTR in place. "In this case, I had no choice but to suture (the CTR)," Dr. Bakewell said, adding that a suture fixation of the CTR using a Hoffman pocket works well. "If there is more than four hours of zonular dehiscence, the CTR needs to be sutured," Dr. Bakewell advised. "Make sure to suture them in 22.5 mm posterior to the limbus." Otherwise, Dr. Bakewell continued, the device may crowd the anterior chamber and cause angle-closure glaucoma. In cases of zonular dehiscence, "I like doing a two-handed CTR insertion. I use a Lester hook in the non-dominant hand and inject with a Geuder injector. It's a lot easier on the bag."

Editors' note: Dr. Bakewell has no financial interests related to his presentation.

SGR close to repeal

ASCRS Government Relations Director Nancey K. McCann gave an update on the future of healthcare reform, and she had big news for attendeesrepealing and replacing SGR legislation is closer now than ever before. "We believe that we're very close on this," Ms. McCann said about one of ASCRS' top priorities.In the past, the House and Senate have enacted short-term "patches" to fix Medicare's SGR. Most recently, the 24% pay cut was averted until March 31. "Temporary fixes have exacerbated the problem," Ms. McCann said. "The cut goes deeper, and it costs more money." Now, Republicans and Democrats are coming together to support legislation that will repeal and replace the SGRa move that would prevent a 24% reduction on April 1, provide for a five-year period of stability with positive updates of 0.5%, and preserve fee-for-service as a continued viable option. Three bipartisan bills from the three committees of jurisdiction were passed out of their respective committees. "We opposed any bills that had a 10-year freeze and a budget neutral value-based payment system. We stood firm on that," Ms. McCann said. As a result, the three bills were merged into one bill and introduced in the House and Senate as the SGR Repeal and Medicare Provider Payment Modernization Act. The bill repeals the SGR immediately and provides for five years of a positive update of 0.5%. In addition, the bill consolidates three existing quality programs (PQRS, EHR/meaningful use, and value-based payment modifier), eliminates the current penalties associated with them and creates the Merit-Based Incentive Payment System (MIPS). The new system rewards providers who meet performance thresholds and penalizes those who do not, according to Ms. McCann. The bill also provides a 5% bonus to providers who receive a significant portion of their revenue from an Advanced Payment Model, prohibits the use of quality performance measures as "standards of care" in medical malpractice claims, and requires all EHRs to be interoperable by 2017. "Most importantly, this bill eliminates penalties," Ms. McCann said. "All physicians can get a positive update if they reach the threshold." The biggest obstacle at this point is getting the two sides to agree on appropriate offsets to pay for the legislation, Ms. McCann added. In addition to the SGR, Ms. McCann identified ASCRS' other top priorities: advocating for Medicare private contracting; repealing the Independent Payment Advisory Board (IPAB); working for the elimination of the cataract outcomes measure for ASC quality reporting; resolving ACO exclusivity; and fighting for continued access to compounded drugs. She asked that ASCRS members get involved. "Contact your members of congress. We make it really easy for you on our website," Ms. McCann said. "(Legislators) have to hear from physicians. I cannot emphasize that enough."

Editors' note: Ms. McCann has no financial interests related to her presentation.

Interactive cornea

The "Interactive Cornea" session highlighted a number of issues with presentations on five different topics, followed by an interactive discussion where the panel addressed specific cases and discussed their approach, concerns, pearls, and treatment options in these cases. The session was moderated by W. Barry Lee, MD, Atlanta, and panelists included Vincent P. de Luise, MD, New Haven, Conn., Jonathan B. Rubenstein, MD, Chicago, and Roger F. Steinert, MD, Irvine, Calif.

Dr. Lee presented on both corneal considerations in cataract surgery and contact lens complications. Some cornea considerations that are important to note before cataract surgery include dry eye disease/blepharitis, anterior corneal dystrophies, corneal degenerations like Salzmann's or pterygium, corneal ectatic disorders/astigmatism, posterior corneal dystrophies and IOL selection in corneal disease, he said. Dr. Rubenstein touched on the topic of HSV keratitis for the comprehensive ophthalmologist, giving an overview of the herpes simplex virus. He went over clinical infection, the ocular manifestations of HSV that could be seen, when the virus becomes latent and localizes, and possibilities for recurrence.

Dr. de Luise presented on scleritis and episcleritis, highlighting the differences between the two and possible treatments.

Dr. Steinert discussed cataract surgery in high astigmatism, specifically looking at toric IOLs for the correction of high amounts of astigmatism after penetrating keratoplasty. He said the main question he wanted to answer was what are the issues with the toric IOL when you have enough astigmatism that it's not easily correctable with spectacles from a patient satisfaction point of view? Dr. Steinert presented a retrospective review he worked on with 21 eyes of 16 patients with astigmatism of greater than 2.5 D after a zig-zag incision FLEK PKP. He looked at the status of the patients post full suture removal because the sutures themselves often cause astigmatism that will not be there when they are removed. The patients were treated using a toric intraocular lens, the AcrySof IQ Toric IOL (Alcon, Fort Worth, Texas). The mean follow-up was a little over a year. The outcome measures showed uncorrected distance visual acuity (UDVA), spectacle corrected distance visual acuity (CDVA), and postoperative manifest refraction astigmatism compared to the preoperative topographic astigmatism. He said that toric IOLs after femtosecond penetrating keratoplasty do improve the uncorrected and best corrected acuities. There are, however, some optical concerns for toric IOLs, including limited upper range of correction. "One [concern] is that we currently in the United States are limited at four diopters," Dr. Steinert said. This type of treatment does not correct for higher order aberrations or irregular astigmatism. He said he uses corneal topography, and fortunately with the femtosecond incision, it's more likely that there will be less higher order aberration and more regular astigmatism, even when there is high astigmatism. "I think toric IOLs are a wonderful new therapeutic alternative to get visual function restored in these patients once the sutures are out and they have regular astigmatism," Dr. Steinert said.

Editors' note: The physicians have no financial interests related to their presentations.

Preparing for ICD-10

E. Ann Rose, president of Rose & Associates, Duncanville, Texas, spoke about ICD-10 and preparing for implementation. The go-live date is set for October 1, 2014, and this date is firm and not expected to change, based on CMS guidelines. Any provider covered by HIPAA must convert, with only a few exceptions. These include providers other than Medicare and Medicaid, with the exception of workers' compensation, auto insurance, home owners' insurance, and business owner liability. In order to prepare for ICD-10, Ms. Rose said there are several things that should be done now. She said that each practice needs to identify how it will be affected by ICD-10. Creating a timeline chart and setting deadlines for completion; implementing strategies to address areas that are weak or lacking; and reviewing policies or procedures involving a diagnosis code, disease management, tracking or appeals process are other steps to take. Additionally, she said to make a checklist of everything you need to do to prepare for ICD-10. This checklist should include developing a project plan, getting other staff involved, estimating a secure budget for a number of issues that could arise, reaching out to your software vendor, touching base with your clearinghouse, talking to commercial payers about their testing options, ordering new CMS-1500 claim forms, upgrading computer systems to handle new claim forms, updating superbills and encounter forms, improving chart documentation, setting aside cash reserves, establishing a bigger line of credit at the bank, setting aside a three-month reserve to allow for any problems to get corrected, scheduling ICD-10 training, preparing for contingencies, and identifying solutions. Ms. Rose said that the AHIMA recommends that ICD-10 training be done six months before the compliance deadline. Finally, she highlighted some key information about implementation and emphasized the importance of anticipating problems and resistance to change that could come with the implementation.

Editors' note: Ms. Rose has no financial interests related to her presentation.

Saturday, Feb. 15

The ASCRS•ASOA Winter Update opened Saturday with a "What's New in Technology" session, which was moderated by Roger F. Steinert, MD, Irvine Calif. Other faculty in the session included Garry P. Condon, MD, Pittsburgh, Brendan J. Moriarty, MD, Cheshire, U.K., Robert H. Osher, MD, Blue Ash, Ohio, Jonathan B. Rubenstein, MD, Chicago, Thomas W. Samuelson, MD, Minneapolis, and Kerry D. Solomon, MD, Mt. Pleasant, S.C. Dr. Rubenstein discussed what's new in endothelial keratoplasty (EK). He mentioned the causes for a compromised endothelium in cataract patients, which include Fuchs' dystrophy, advanced age, history of angle closure, history of trauma, chronic inflammation, and previous anterior segment surgery. "Fuchs' is the major one we deal with," he said. EK falls into several different categories, such as penetrating keratoplasty (PK), deep lamellar endothelial keratoplasty (DLEK), Descemet's stripping endothelial keratoplasty (DSEK), Descemet's membrane automated endothelial keratoplasty (DMAEK), and Descemet's membrane endothelial keratoplasty (DMEK). DLEK is not done as much anymore, he said. DSEK is a thinner form of EK, and DMEK is the procedure that many surgeons are moving toward now. "DSEK is still the most widely done of all the procedures of endothelial keratoplasty," Dr. Rubenstein said. "The biggest news in DSEK is the advances in inserters." These include the Neusidl Corneal Inserter (Fischer Surgical, Imperial, Mo.), the Tan EndoGlide (Angiotech, Vancouver), the Busin Glide (Moria, Doylestown, Pa.), and the EndoSerter (Ocular Systems, Winston-Salem, N.C.). Another development in DSEK is moving toward ultra-thin DSEK. There is a debate in the cornea community about whether ultra-thin DSEK or DMEK is better. Ultra-thin DSEK uses the same technique as DSEK but with thinner graft tissue, he said. The ultra-thin procedure uses grafts of 80100 microns and it has a possibly higher rate of 20/20 VA compared to DSEK. Visual results for ultra-thin DSEK are similar to what's proposed for DMEK. "The advantage of this over DMEK is a lower rate of donor tissue waste," he said, as well as a lower rebubbling rate.

Dr. Samuelson discussed the next generation of microinvasive glaucoma surgery, or MIGS. One of the new and upcoming innovations, he said, is the AqueSys XEN (AqueSys, Aliso Viejo, Calif.). Although it is not yet approved for use in the United States, he said that it has the potential for extremely good efficacy. No one would argue that trabeculectomy and tubes are efficacious, but the question is how safe they are. The XEN is a portfolio that features three different sizes of gelatinous stents, and these provide communication between the anterior chamber and the subconjunctival space. Other features of the AqueSys product are that the stents are soft, compressible and tissue conforming, and come pre-loaded with a disposable injector. It largely spares the conjunctiva and is an excellent option for a variety of patient types, including those with moderate to advanced glaucoma, who have failed MIGS and those who are pseudophakic, Dr. Samuelson said. If safety is proved, perhaps it can compete with canal-based procedures. Dr. Samuelson said he has done a lot of cases with the XEN in the Dominican Republic and some in the United States as part of a trial. He said there is significant efficacy with the product. "You can get pressures that are significantly lower than canal-based procedures. It's minimally invasive in terms of its technique." He added that it still needs to be proven whether or not the XEN is minimally invasive in terms of mechanism.

Editors' note: Dr. Rubenstein has no financial interests related to his presentation. Dr. Samuelson has financial interests with AqueSys.

Management of complex cataracts

An afternoon session led by Dr. Condon focused on managing complex cataracts. "The most challenging cataract scenarios that we typically see are the patients with very dense lenses and the patients with very loose lenses, and the pseudoexfoliation cases," he said. He discussed several particularly dense and challenging cataracts and showed videos, offering tips for how to handle these cases. Dr. Condon has several ways to deal with complex cataracts. "My approach to dealing with these lenses over the years is two-fold," he said. The first point is to protect the corneal endothelium as much as possible. The second point is to address the cataract in the capsular bag. "I try to remove as much of these lenses as possible while they're in the capsular bag," he said. "I don't try and get to the chop point." If you do this, the lens is in a well-controlled position, and phaco is used behind the plane of the anterior capsular lens, Dr. Condon said.

Editors' note: Dr. Condon has no financial interests related to his presentation.

Rapid F-Eye-R

A panel of physicians shared quick pearls on topics ranging from femtosecond technology to microinvasive glaucoma surgery (MIGS) in short presentations during the popular "Rapid F-Eye-R" session. In the first discussion, Dr. Solomon touted the benefits of toric IOLs for astigmatism correction, but said the technology isn't reaching enough patients. "We've just barely scratched the surface," he said. "Fifty percent of patients in your practice are eligible for a toric lens, so we have a long way to go." Next, the panelists debated the use of the femtosecond laser. "The price tag is so much that a lot of practices are going to wait to see what happens," said Brock K. Bakewell, MD, Tucson, Ariz. "I think it makes me a better surgeon," Dr. Solomon said. "I think it's improving my outcomes, and it's the next step of the future." Eric D. Donnenfeld, MD, Rockville Centre, N.Y., agreed. "There's not a single doubt in my mind that it will not only be around but will be the dominant form of cataract surgery," Dr. Donnenfeld said. "There have been 80 peer-reviewed papers on femtosecond laser-assisted cataract surgery, and almost all of them are showing positive signs."

In a session called "What am I doing new this year?" Dr. Bakewell gave pearls about transitioning to an electronic health record (EHR) system: In a multi-doctor practice, switch only one doctor at a time; start with younger doctors who are more tech savvy; decrease the daily patient schedule by 20 to 25% for the first month, then ramp back up; phase in each doctor every one to two months; and have the doctors give feedback to the EHR committee to help them improve templates. "Also, definitely have a scribe to put information into the computer," Dr. Bakewell. "I have two scribes who allow me to see 50 patients a day." Dr. Steinert said the new item he is using in practice is the OPD-Scan III (Nidek, Fremont, Calif.), an advanced vision-assessment system that combines topography, wavefront, autorefraction, keratometry, and pupillometry to analyze corneal aberration. When the audience was polled on which technologies they find the most exciting, MIGS was the number one answer. But when MIGS isn't enough, another option coming down the pipe is the InnFocus MicroShunt, according to Dr. Condon who spoke in the "New technology on the horizon" segment. The shunt, which is not yet FDA approved, is for more advanced disease when the surgeon is aiming for more effective pressure lowering, Dr. Condon said. "So far the results have been quite optimistic. It's a very straightforward procedure to do."

Editors' note: Dr. Donnenfeld has financial interests with Abbott Medical Optics, Alcon, and Bausch + Lomb. Drs. Bakewell, Steinert, and Condon have no financial interests related to their presentations.

Sunday, February 16

The ASCRS•ASOA Winter Update program opened on Sunday with "My Top 5 Pearls," where a number of physicians shared their pearls for dealing with specific situations and conditions. The session was moderated by David F. Chang, MD, Los Altos, Calif., and it also featured Roger F. Steinert, MD, Irvine, Calif., Vincent P. de Luise, MD, Waterbury, Conn., Richard A. Lewis, MD, Sacramento, Calif., Brock K. Bakewell, MD, Tucson, Ariz., Thomas W. Samuelson, MD, Minneapolis, Eric D. Donnenfeld, MD, Rockville Centre, N.Y., Jonathan B. Rubenstein, MD, Chicago, and Kerry D. Solomon, MD, Mt. Pleasant, S.C. Dr. de Luise gave pearls for phacoemulsification in eyes with keratopathy. "Cataract surgery is virtually always elective," he said. "Treat the keratopathy first." He also advised to stabilize the corneal surface and optimize pre-corneal tear film. It is only after all of this is done that you should proceed with phaco, Dr. de Luise said. Dr. Lewis also discussed phaco and offered pearls specifically for phaco in glaucoma patients. His five pearls involved dilation, premium lens offerings for glaucoma patients, femtosecond laser cataract surgery, whether or not to stop or continue glaucoma meds, and the combination of glaucoma and cataract surgery. "Dilation is a very important issue in glaucoma patients undergoing cataract surgery," Dr. Lewis said. For premium IOLs in glaucoma patients, Dr. Lewis said toric IOLs can be useful, and it's surprising how few are used. With these IOLs, preoperative measurements and meticulous surgery are essential for good results. Multifocal IOLs, on the other hand, have very limited use in glaucoma patients with field loss, he said. For these premium lenses, the determination of axis and power are extremely important, which involve manual Ks, auto Ks, and topography. Dr. Lewis' next point was about femtosecond laser cataract surgery for glaucoma patients. "The patient interface does cause a slight pressure elevation," he said, but this is the only real con. The positives far outweigh the negatives, and the positive points include precision (especially with capsulotomy), use with loose zonules, astigmatism management, and greater safety. The postoperative IOP management of a cataract patient on glaucoma medication depends on the extent of glaucoma damage, diagnosis and other systemic problems. Dr. Lewis' last pearl involved microinvasive glaucoma surgery, or MIGS, which he said is here to stay, so it's important to get comfortable with the technology and applications. "There's definitely a learning curve," he said.

Dr. Bakewell spoke on the white, mature lens. "The first thing is, you want to use capsular dye," he said. Other pearls are to minimize the posterior pressure, use appropriate OVD, and decompress both the anterior and posterior cortical spaces. Finally, "keep the capsulorhexis small in case the posterior cortical space still has increased pressure," he said, suggesting that the capsulorhexis should be about 3 to 4 millimeters. His bonus pearl was that the femto rhexis may be the ultimate solution. Dr. Steinert addressed astigmatism in cataract patients. His first pearl was to always do preoperative corneal topography. He also said not to be fooled by refraction and that lenticular astigmatism is real. He suggested using Koch's rule for posterior corneal astigmatism correction, but added that there is no current technology that reliably measures posterior corneal astigmatism. "At least consider intraoperative aberrometry," Dr. Steinert said for his fourth pearl. As his last point, he said to wait to address the problem if the toric IOL is malpositioned postoperatively.

Editors' note: Drs. de Luise, Bakewell and Steinert have no financial interests related to his presentation. Dr. Lewis has financial interests with Aerie, Alcon, Allergan, AqueSys, Glaukos, and Ivantis.

Cornea case management

The "Cornea Case Management" session was an interactive workshop led by Dr. Rubenstein, Dr. de Luise, and W. Barry Lee, MD, Atlanta. One topic that was discussed was DMEK, which Dr. Rubenstein said is slowing gaining momentum to become accepted in the ophthalmic community. He highlighted some important points in the advantages of DMEK. He said that eye banks are preparing the tissue ahead of time, meaning that there's no need for surgeons to dissect the Descemet's membrane themselves. He also said there is a better delivery system now, a modified Jones Tube developed by Michael Straiko, MD, Portland, Ore. Dr. Rubenstein said that he uses SF6 gas in DMEK.

Editors' note: Dr. Rubenstein has no financial interests related to his presentation.

Glaucoma tips and tricks

In a session called "Updating your glaucoma treatment armamentarium," a panel of experts provided pearls for treatment of the disease. Dr. Lewis uses gonioscopy and optical coherence tomography (OCT) to diagnose narrow angles. "The advent of OCT has really helped," he said. "It's doesn't take a specialist to do this. You can image the angle and make treatment plans based on your OCT. And it's reimbursable. There's no reason not to do it."

"Spectral domain OCT has provided definitive information about the angle that we never could appreciate before," Dr. Lewis said. It's especially helpful in explaining to patients why they need a laser iridotomy. A YAG peripheral iridotomy helps prevent angle closure in high-risk patients. "Lens removal is necessary in high hyperopia and lens-induced glaucomas," Dr. Lewis said. It is contraindicated when a growing angle melanoma causes the angle closure or when a lens is subluxed. Dr. Lewis told attendees to consider a retrobulbar block in patients who have severe pain from angle-closure glaucoma. The block immediately and "impressively" calms a patient and prepares them for further treatment, Dr. Lewis advised. "It's the most dramatic thing I have seen in angle-closure glaucoma," he said. "It doesn't lower the pressure, but it alleviates the nausea and vomiting."

In his talk, Dr. Samuelson offered "Five Glaucoma Management Pearls for 2014." First, he advised surgeons to select and master a microinvasive glaucoma surgery (MIGS). "You want to have one of these technologies to offer your patient population." Dr. Samuelson said some definitions of MIGS procedures require an ab interno approach. He prefers canal-based stenting surgeries. "My bias for canal-based procedures is that the safety has been proven," he said. Second, Dr. Samuelson said practitioners should individualize their glaucoma surgery depending on the patient. Third, three drugs for glaucoma patients might be enough. A fourth medication doesn't add anything. "We are finally seeing investment in surgical glaucoma," he said. "I would gladly give up prescribing fourth medications, and I would gladly cut back on diagnostic expenditures to help finance innovative and improved glaucoma procedures." Fourth, when implanting the iStent, don't expect blood to reflux right away, Dr. Samuelson said. "It's a nice sign, but quite often you don't see it until the eye is soft after you remove all visco from behind the implant," he said. Finally, surgeons should know how to manage a failed EX-PRESS Glaucoma Filtration Device (Alcon). "Don't declare an EX-PRESS trab as a failure until you consider a YAG," Dr. Samuelson advised. Steven R. Sarkisian Jr., MD, Oklahoma City, offered his tips for fitting an ab interno trabecular bypass into practice. "The key here is that you're not hurting the patient, even if it fails spectacularly," he said about adopting the iStent (Glaukos, Laguna Hills, Calif.). "You still have all of the options open to you." Dr. Sarkisian then showed a few of his first not-so-perfect cases to illustrate the procedure's learning curve. "It is the most delicate thing I do as an anterior segment surgeon," Dr. Lewis said. "It probably takes 10, 20, 30 procedures to get really good at this." Dr. Sarkisian said surgeons should pick simpler cases for their first few iStent procedures. "Pick someone who's controlled. Don't pick a traumatic case," he said. Primary open-angle glaucoma patients are good; PG patients are better because their scleral spur is easier to find. "They have those nice landmarks," Dr. Sarkisian said. "They have a runway for you to put in the iStent." Also, because iStent implantation is only FDA approved for use in conjunction with a cataract procedure, Dr. Sarkisian advised surgeons look for a routine phaco procedure. "Don't pick a patient with corneal disease or low endothelial cell count," he said. "If you have edema after phaco and you're trying to do the iStent, you might have an issue."

Editors' note: Dr. Lewis has no financial interests related to his presentation. Dr. Samuelson has financial interests with Alcon and Glaukos. Dr. Sarkisian has financial interests with Glaukos.

Monday, February 17

The ASCRS•ASOA Winter Update opened its final day on Monday with a session titled "Refractive Surgery: Challenges and Improvements." Moderated by Eric D. Donnenfeld, MD, Rockville Centre, N.Y., it explored case presentations with interactive discussions from other faculty, including W. Barry Lee, MD, Atlanta, Jonathan B. Rubenstein, MD, Chicago, Larry E. Patterson, MD, Crossville, Tenn., and Roger F. Steinert, MD, Irvine, Calif. The panel addressed a number of topics including astigmatism, dealing with infections, and choosing the correct procedures and lenses for particular patients.

Dr. Donnenfeld presented a case of a 63-year-old male patient who was six years postoperative after having LASIK in both eyes. At that point, the patient developed a cataract. The case had been a very straightforward LASIK case, he said, and the patient wanted visual rehabilitation. Dr. Steinert said that in this case, whether the patient wanted to focus on distance, monovision, or something else, the most important thing is to be very accurate. The other question to ask, Dr. Steinert said, is if you should ever offer this patient a multifocal lens because it may be challenging to use a multifocal IOL in a post-LASIK patient. He said when considering the possibility of a multifocal lens, look for patients who are otherwise very happy with their vision and have pristine topography. Ultimately, Dr. Donnenfeld said that the patient did well with a bilateral diffractive multifocal IOL implantation. In order to determine if this was the correct choice, he first looked at the topography and the ablation profile of the patient.

Based on a question from the audience, the panel discussed whether they would do a PRK or LASIK procedure on a person with a history of herpes simplex. Dr. Rubenstein said that he would consider doing these procedures in this type of patient, but only if the cornea was clear with the ability to get good readings and if there was no scarring. He said he would start this patient on oral antivirals before treatment and continue for a couple of weeks after treatment. Dr. Donnenfeld noted that he would be more inclined toward using LASIK in this situation and would be certain to check the corneal sensation. Use of the femtosecond laser also came up in the discussion of limbal relaxing incisions (LRIs) and femtosecond laser arc incisions. The panel discussed how use of the femtosecond laser may have an advantage over manual incisions for LRIs. LRIs are very technique dependent, Dr. Rubenstein said. You have to correct for different directions and during the course of the LRI, the blade depth and angles need to be correct during the entire incision, he said. When using the femtosecond laser, you can completely control every aspect of the incision, which means there's greater potential for accuracy. Dr. Donnenfeld discussed a patient who had severe complications after a PRK procedure. He posed the question of whether PRK or LASIK is a safer procedure. Initially, he told the patient that PRK would be safer because there is less chance of ectasia. However, he noted that LASIK may be safer because it has a reduced risk of infection. Physicians often assume PRK is safer when doing refractive surgery, Dr. Donnenfeld said, however the risk of infection is five times higher with PRK. Additionally, with use of the femtosecond laser, this could help to eliminate some of the complications and difficulties that can arise when doing a microkeratome LASIK procedure. For a lower volume surgeon who's not comfortable doing LASIK, PRK is the way to go, he said. But LASIK may be a better choice and may offer a better experience for the patient.

Dr. Donnenfeld discussed using crosslinking in his practice and specifically addressed the potential benefits of using crosslinking with a radial keratotomy (RK). He said that crosslinking can help decrease visual fluctuation and moderate corneal flattening in these cases because visual fluctuation can be a problem with RK.

Editors' note: The physicians have no financial interests related to their presentations.

About ethics

In the "Ethics Interactive" session, John D. Banja, PhD, Atlanta, led a panel discussion on scope of practice and a number of issues related to the topic. Other panel members included Dr. Donnenfeld, Dr. Lee, and Dr. Rubenstein. Dr. Banja started by outlining scope of practice and parameters for ethical guidelines. Four main points are autonomy, non-maleficence, beneficence, and justice. He highlighted non-maleficence and beneficence, which boils down to "do no harm" and doing good. The only factors relevant to scope of practice decision-making are those designed to ensure that all licensed practitioners are capable of providing competent care, he said. Dr. Donnenfeld also highlighted the principle of beneficence, which is "a concept in research ethics that states that researchers should have the welfare of the research participant as a goal of any clinical trial." "We all think in terms of effectiveness in how we measure success," Dr. Donnenfeld said. However, in today's society, you also have to consider cost effectiveness. Something much less costly and almost as effective is considered as beneficence, too, and you have to take that into account.

The discussion shifted to standard of care, and Dr. Banja said that although this evolves, it does not necessarily do so in a clean and logical way. Standard of care is also influenced by socioeconomics and technology, he said. Another discussion centered around prescribing drugs and insurance, which is getting more expensive. "Be sensitive to what is covered by insurance in your area, and be sensitive to the pocketbook of the patient," Dr. Donnenfeld said, adding that when he prescribes a name-brand medication, he also gives the patient a back-up generic choice. In those cases, he provides a handout with the correct dosages of each. Too much time was being spent going back and forth with patients and pharmacies

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