March 2016

 

MEETING REPORTER

 

Reporting from the 2016

World Ophthalmology Congress


 
 

Reporting from the 2016 World Ophthalmology Congress, February 59, Guadalajara, Mexico

 

View videos from WOC 2016: EWrePlay.org

Roberto Bellucci, MD, discusses indications for superficial lamellar keratectomy.

View videos from WOC 2016: EWrePlay.org

Bruce Koffler, MD, discusses the use of orthokeratology in children.

View videos from WOC 2016: EWrePlay.org

Shamira Perera, MD, discusses several indications for laser iridoplasty.

View videos from WOC 2016: EWrePlay.org

Richard Packard, MD, discusses advances in cataract surgery in the last 2 years.

View videos from WOC 2016: EWrePlay.org

Marie-Jose Tassignon, MD, discusses the bag-in-the-lens procedure with a toric IOL.

View videos from WOC 2016: EWrePlay.org

David F. Chang, MD, discusses the use of intracameral antibiotics for endophthalmitis prophylaxis.

View videos from WOC 2016: EWrePlay.org

Warren Hill, MD, discusses the central role of contrast sensitivity in visual function and its implications in IOL selection.

Surgeons must weigh RLE pros and cons, consider patient selection

Refractive lens exchange (RLE) can have good outcomes if surgeons carefully select patients, said physicians presenting at Refractive Lens Exchange: Indications, Limitations and Outcomes. The role of the surgeon is key to patient satisfaction, and surgeons must rely on clinical judgment, said Cecilio Velasco Barona, MD, Mexico City.

Although RLE can be successful, its better to consider it an alternative to corneal refractive surgery rather than a primary procedure, said Jorge Ali, MD, Alicante, Spain. Refractive lens exchange can be riskier and have less precise outcomes, he explained. Dr. Ali discussed RLE in a variety of patient circumstances, including myopia, hyperopia, and astigmatism. Sheraz Daya, MD, London, focused on RLE for patients age 55 and over; the use of RLE in patients age 30 to 50 is more controversial, he said. One major reason is that you may be removing a patients intact visual optics. If you take a good set of visual optics and destroy them, the patient wont forgive you, he said.

Options he considers more frequently in younger patients are laser in situ keratomileusis (LASIK), phakic IOLs, and Supracor LASIK. Another consideration is that endophthalmitis, cystoid macular edema, and retinal detachment (RD) all can be more common in the 30- to 50-year-old age group. Some factors to consider with the risk for RD include a longer axial length, myopia, and surgical complications, Dr. Daya said. George Beiko, MD, St. Catharines, Canada, reviewed how he chooses IOLs in RLE patients. In patients under the age of 50 who are ametropic, he prefers to use phakic IOLs such as the Artisan (Ophtec, Groningen, the Netherlands) or perform RLE if the patient needs only a +1, +2, or +3 D lens. In patients older than 50 who are ametropic or presbyopic, he uses the Tecnis (Abbott Medical Optics, Abbott Park, Ill.), enVista (Bausch + Lomb, Bridgewater, N.J.), or the Tecnis multifocal. He also uses phakic lenses (4 D or higher) for myopia in the older patient group. Dr. Beikos favored IOL is a one-piece aspheric, hydrophobic, acrylic, glistening-free, 360-degree square edge one, which he said that several manufacturers make.

Its important to think about the tradeoff for patients between better visual quality with a monofocal IOL versus spectacle independence with a multifocal IOL. You cant do both, he said.

When meeting with RLE patients, Dr. Beiko warns them that they may not hit their refractive target and could need a secondary correctionwhich happens in about 10% to 20% of patients. Preparing patients for what to realistically expect from RLE is crucial, Dr. Velasco Barona said. Like other presenters, he discussed risks associated with RLE, including posterior capsule opacification (more common in patients with longer axial lengths), RD (a greater risk in patients with posterior capsule tears, zonular dehiscence, and lattice degeneration), and side effects such as glare and halo. In fact, more than 65% of patients can experience glare and halo, even if they can go about their visual tasks normally, Dr. Velasco Barona said.

Options in corneal transplantation

A session titled Dissecting the Cornea highlighted a number of options for corneal transplantation. Nicolas Cesario Pereira, MD, So Paulo, Brazil, shared some pearls for those trying to master DMEK. The procedure has a learning curve, he said. He highlighted several surgical strategies for handling DMEK. First, Dr. Pereira said that obtaining a soft eye is important. Intraoperative posterior pressure is one of the main causes of complicated tissue handling, he said. This makes it more difficult to maintain the air in the anterior chamber. To obtain a soft eye, surgeons may want to use an anti-Trendelenburg position and a manual ocular massage for 2 minutes and Honan balloon for 10 minutes. Then, check the tightness of the eyelid speculum, he said.

Inferior peripheral iridectomy is also important. Dr. Pereira said that a near complete air fill can be left without the risk of pupillary block, although he noted that there is a higher risk in phakic patients. When doing the main incision, he recommended a superior clear corneal tunnel incision of 2.2 to 3.0 mm, and the graft should seal the incision. Meanwhile, the descemetorhexis should be the same size or a little bit larger than the graft.

Check for the presence of Descemets membrane (DM) remnants, Dr. Pereira advised. After stripping and tissue removal, check for the presence of DM remnants with air and balanced salt solution because these remnants can affect visual acuity and adherence. To implant the DMEK graft, Dr. Pereira said that a number of options may be used, including a custom-made glass injector, a glass pipette, or a modified IOL injector. A double roll facing upward facilitates the graft opening in the correct position, and when orienting the DMEK graft, correct orientation must be confirmed before unfolding. Surgeons may want to unfold the graft by tapping the outer corneal surface, he said. You can unfold with a small air bubble, by rolling on top of the membrane, or by direct balanced salt solution injection and/or manipulation. Centering the DMEK graft is critical, as a large decentration can result in an overlap of DM, which contributes to a higher risk of graft detachment. Centration can be aided by a gentle stroke with the cannula over the corneal surface.

When fixating the DMEK graft, Dr. Pereira recommended filling the anterior chamber completely with air at 30 to 40 mm Hg for 20 to 40 minutes. Then, he said, lower the pressure to around 20 mm Hg. With an inferior iridectomy, a near complete air fill can be left, he said. In conclusion, Dr. Pereira said that mastering DMEK is all about having a simplified reproducible technique with low complication rates and being really precise in our technique.

Glaucoma in 2016

Remo Susanna Jr., MD, So Paulo, Brazil, highlighted peak IOP detection and the importance in glaucoma management. There are a number of ways to assess IOP peak, he said, but some of these tests are not as effective as others. Possible ways to assess this include 24-hour diurnal-nocturnal tension curve, daytime tension curve, single IOP measurements in several days, continuous IOP monitoring, or a water-drinking test. He thinks that the water-drinking test (WDT) is the best and most practical way to determine IOP. With this test, the patient is required to drink 800 ml (27 ounces) of tap water in 5 minutes. The IOP is then measured 3 times at 15-minute intervals, and the maximum value of the 3 measurements is considered the maximum IOP for the test. Using a WDT is a reproducible and reliable parameter, he said.

Dr. Susanna stressed two important take-home messages. The first was that peak IOP is a constant and crucial parameter, which is independent of initial IOP and underscores a patients likelihood of future progression. The second point was that drugs that show a similar mean IOP reduction but better ability to avoid IOP peaks may have an additional benefit for glaucoma treatment.

Considering KPro advantages and complications

Glaucoma drainage device complication can be the Mount Everest in patients with the Boston keratoprosthesis (KPro, Massachusetts Eye and Ear Infirmary, Boston), said Jennifer Li, MD, Sacramento, Calif., in the session Ocular Surface and Keratoprosthesis. Thats because while the device has several complications, the most pervasive problem is complications associated with glaucoma drainage devices, she explained. Patients using the KPro who have glaucoma drainage devices likely have had multiple procedures and other complications, Dr. Li explained.

Although some surgeons argue that tube shunts should be inserted at the same time the KPro is used, that approach doesnt always work. Postoperative glaucoma can continue to be a problem, she said.

Possible solutions to this prevalent problem include covering older devices again, considering pars plana insertion, using a longer length of tube in the anterior chamber, and changing the contact lens diameter.

Despite complications, patients with a KPro as the primary procedure tend to have more consistent visual success at 24 years postoperatively, according to data from Anthony Aldave, MD, Los Angeles. The work he has done in this area compared patients with KPro against those with multiple penetrating keratoplasty procedures, and he found that 70% of eyes were better than 20/200 through 4 years. If youre considering penetrating keratoplasty in a patient who has a low chance for success, Dr. Aldave thinks that the KPro may be a better choice.

Surgeons talk glaucoma research and innovations

When Robert Ritch, MD, New York, first brought up the possible connection between glaucoma and lifestyle and nutrition 20 years ago, people thought he was joking.

Fast forward to 2016. Now, theres a vast increase in interest and importance in the topic, Dr. Ritch told attendees during the session New Clinical Pearls to Assess and Manage Glaucoma. Despite the strong interest, ophthalmology still needs more clinical trials to truly show which of these less common therapies can help prevent or reduce the effects of glaucoma.

Although there is no evidence of natural compounds that can lower IOP, there is research that sheds light on how they can benefit other biological functions that play a role in glaucoma, Dr. Ritch said. This includes lowering blood pressure, providing neuroprotection, and helping brain function.

We have to think of glaucoma as a brain disease and not an eye disease, he said.

One such natural compound is ginkgo biloba, which has been used in Chinese medicine for thousands of years, Dr. Ritch said. Its a powerful antioxidant and has been shown in many research models to be neuroprotective while also improving blood flow. Some studies show that ginkgo biloba protects against degeneration in the trabecular meshwork as well.

There is also curcumin, which has beneficial effects for diabetic retinopathy, uveitis, ocular surface disease, and possibly glaucoma, Dr. Ritch said. Interest in curcumin has exploded, with more than 8,500 related studies in progress on PubMed, he added. Other supplements under research are omega-3 fatty acidsalready used by some patients to help with ocular surface diseaseand citicoline, Dr. Ritch said.

Exercise is another more natural therapy that many within medicine have researched and found benefits related to oxidative stress. Exercises role in glaucoma may be additive along with diet and supplements, he explained. However, glaucoma patients should be careful to avoid inversion poses in yoga that may actually increase instead of lower IOP, Dr. Ritch cautioned.

Neeru Gupta, MD, Toronto, addressed biomarkers for glaucoma damage, noting that IOP, vascular signs, genetics, proteomics, newer vision tests, and neuroimaging all may be used now or in the future for this purpose.

One area of particular interest right now is brain-related biomarkersincluding structure, perfusion, activity, connection, and metabolismas researchers try to track a stronger connection between the brain and glaucoma. The ultimate goal is to develop disease-modifying therapies, Dr. Gupta said.

Prin Rojanapongpun, MD, Bangkok, discussed the tricky balance between benefits and complications from trabeculectomy. He cited data from a 2015 JAMA Ophthalmology study that found one-fifth of patients who have trabeculectomy will have early complications, and one-fourth will have late complications. The study, which focused on 20 years of follow-up from the Olmstead, Minn., population, found a 53% or larger decrease in trabeculectomy over time as surgeons were able to use other treatments. Some alternatives or adjuncts to trabeculectomy that surgeons can now use include microinvasive glaucoma surgery (MIGS), the EX-PRESS Glaucoma Filtration Device (Alcon, Fort Worth, Texas), the collagen matrix Ologen (Aeon Astron, East Brunswick, N.J.) used in conjunction with trabeculectomy, and the combination of phacoemulsification with trabeculectomy.

Wave of advances reaches cornea disease, cataract surgery, and refractive surgery

Corneal crosslinking (CXL), limbal stem cells, epigenetics, and exosomes are hot areas in corneal and external diseaseand research in these areas will continue to grow in the coming years, said Sally Atherton, PhD, Augusta, Ga., speaking during the WOC Day of Landmark Achievements (20142016): Cornea and External Eye Disease, Cataract Surgery, Nanotechnology and Bioengineering, and Refractive Surgery. Although not yet approved in the U.S., CXL is used abroad to treat keratoconus as well as infectious keratitis, Dr. Atherton said. A meta-analysis published this year in Cornea found that CXL was effective in treating bacterial, Acanthamoeba, and fungal keratitis, but it was not effective for herpes simplex and resulted in corneal melt in the latter patient group. There are some concerns with CXL treatment and resurgence and perforation. Crosslinking may strengthen the cornea but may create a reservoir for microorganisms to persist, she said. Limbal stem cells are increasingly studied and have become a hot topic for use in ocular surface reconstruction as well as other applications.

Epigenetics is a buzz word these days in medical research, and its study may one day reveal clues on how to treat and prevent corneal disease, Dr. Atherton said. Dr. Atherton also discussed exosomes, which are cell-derived vesicles that may ameliorate or exacerbate disease. Some reports say they could be used to circumvent the hurdles of stem cells, she said. Cataract surgery has seen a plethora of advancements in a short time period, said Richard Packard, MD, London. One advance is a new approach to IOL calculations that is based on artificial neural networks. The approach was presented by Warren Hill, MD, Mesa, Ariz., at last years American Academy of Ophthalmology (AAO) meeting in Las Vegas. In a study of more than 3,400 eyes, research from Dr. Hill and collaborators found that 95% of patients came within 0.5 D of the intended target. Thats a remarkable achievement compared with anything weve done before, Dr. Packard said. I think this will revolutionize refractive outcomes. The new IOL calculation method presented originally by Dr. Hill will be part of the LENSTAR (Haag-Streit, Koniz, Switzerland) equipment in the future but will also be available on a dedicated website, Dr. Packard said.

Also related to IOL calculations, technology such as intraoperative optical coherence tomography that can help surgeons find the patients effective lens position has been a game changer, Dr. Packer said.

Other advances in cataract surgery that Dr. Packard highlighted included improved toric IOL calculations, mobile femtosecond lasers, better dilation and pain relief with Omidria (phenylephrine and ketorolac injection, Omeros, Seattle), and new IOLs that can help patients with age-related macular degeneration.

Finally, Peter McDonnell, MD, Baltimore, shared recent advancements within refractive surgery. One issue is presbyopia, which affects up to 2 billion people. The approval of the first lamellar corneal inlay in the U.S., the KAMRA (AcuFocus, Irvine, Calif.), was a major advancement, he said. The KAMRA is mostly used in patients in their early 50s. A 2014 study in the Journal of Refractive Surgery found that one-eighth of KAMRA patients did not need any reading glasses at 2 years postop; other patients reduced their use. Some concerns with KAMRA include epithelial ingrowth, decentration, and infections, Dr. McDonnell said. Up to 10% of patients require removal of the inlay.

Another area that has been researched heavily in the past few years is corneal biomechanics, Dr. McDonnell said. Detecting early signs of keratoconus via a better understanding of corneal biomechanics can help patients avoid problems after refractive surgery. Researchers are analyzing the corneal shape, corneal biomechanical properties, and tomography to glean clues in this area. Clinicians are also reviewing the results of CXL treatment and the small incision lenticule extraction procedureknown as SMILEto analyze their role in helping ectasia.

A third hot topic within refractive surgery is the neurotrophic cornea, Dr. McDonnell said. However, there is much that remains to be done. Our limited knowledge translates into a limited ability to prevent and treat this, he said.

Clinicians highlight advances in ocular oncology, regenerative disease, and pediatric care

Until recently, there were no promising treatments for uveal melanoma, said Jasmine Francis, MD, New York. Although up to 98% of patients can be metastasis-free at diagnosis, more than 50% die from metastases within 15 years. Previous trials that covered existing treatments showed only a 1% response rate.

However, publication of treatment results with selumetinib in 2014 in the journal JAMA added some promise for patients with uveal melanoma. With selumetinib, progression-free survival was 16 weeks versus 7 weeks with chemotherapy, Dr. Francis said, addressing attendees during the WOC Day of Landmark Advancements (20142016): Ocular Oncology and Pathology, Uveitis and Ocular Inflammation, Pediatric Ophthalmology and Strabismus, and Neuroscience and Regenerative Medicine. That said, the overall survival rate was the same in both groups.

Some side effects with selumetinib include an acneiform rash (75%) and fatigue (50%). Thirty-seven percent of patients in the JAMA report required a dose reduction. Still, its a promising therapy, although there is no difference in overall survival, Dr. Francis said.

Dr. Francis also addressed recent treatment for retinoblastoma, the most common primary eye cancer in children. The cancer had a poor survival rate in the past, but now, there is about a 95% survival rate.

Ophthalmic arteric chemosurgery, also known as OAC, has led to fewer tumors in patients, and the treatment has become more common. A 2014 survey showed that 75% of centers worldwide use OAC as a first-line therapy, Dr. Francis said. Vitreous seeding is another recent innovation for the treatment of retinoblastoma, Dr. Francis said.

Pearls for complicated phaco cases

During a session focusing on complicated phaco cases, presenters gave attendees their top 5 pearls for dealing with a number of issues. This was followed by a panel discussion on topics such as intraoperative floppy iris syndrome (IFIS)/small pupils, posterior polar cataracts, pseudoexfoliation/weak zonules, phaco with glaucoma, the rock hard lens, avoiding femtosecond laser complications, and vitreous loss and anterior vitrectomy. Abhay Vasavada, MD, Ahmedabad, India, presented his pearls relating to posterior polar cataract management. His first pearl was to avoid rapid buildup of hydraulic pressure. With this, you dont need to perform hydrodissection, he said. The second pearl was to create a mechanical cushion effect protecting the posterior capsule when performing the procedure. Conventional delineation is fine, he said, but Dr. Vasavada thinks inside-out delineation may be better.

Pearl 3 was to avoid forward bulge of the capsule-zonular diaphragm. When you are done sculpting, Dr. Vasavada said, its important to inject OVD. His next pearl was to create a communication between the anterior and posterior compartments, and pearl 5 was the possible use of femto delineation for posterior polar cataracts.

Dr. Vasavada offered a bonus pearl to preoperatively counsel the patient and family about multiple interventions and IOL fixation options.

Susan MacDonald, MD, Boston, discussed pearls for dealing with anterior vitrectomy. First, she said, prepare your whole team. One of the most important things you can do as a surgeon is to train your OR staff for an unexpected anterior vitrectomy, she said. Its also important that everyone knows that if a vitrectomy isnt performed properly, there may be even more complications. Dr. MacDonald recommended having a vitrectomy kit (either put together or a list of what would be needed).

Improving your visualization of the vitreous was the second pearl Dr. MacDonald offered. Pearl 3 was to maintain chamber pressure. I think the best way to do this is with a bimanual approach, she said. A pars plana approach may also be good, but that will require further education on the surgeons part, she said.

The next pearl was to cut, dont tug, and Dr. MacDonalds final pearl was that you need to suture all of your wounds. This is especially important because these patients are at a higher risk for endophthalmitis and hypotony.

New technologies in refractive imaging and corneal lasers

Time-domain is the standard for OCT, but there are also other OCT options, said Naoyuki Maeda, MD, Osaka, Japan. His presentation focused on 3 other OCT options: spectral domain OCT, swept-source OCT, and full field OCT (a potential option in the future). These all have the potential for a higher resolution than time domain OCT, he said. Swept-source OCT is very fast, Dr. Maeda said. It can cover up to 16 mm so you can capture the whole corneal image. With this machine, Dr. Maeda said he conducted a trend analysis of keratoconus progression, which can be useful for corneal crosslinking. Prediction of IOL position can also be determined with swept-source OCT.

Meanwhile, with spectral domain OCT, the corneal epithelium and stroma can be separated. This also can provide keratoconus detection and epithelium thickness profile regression. Dr. Maeda said that full field OCT is still in a prototype form, but the resolution seems much better with this tool. En face image can be obtained with full field OCT, he said, and this could be used for in vivo biopsy in the future.

Using femto flap for optimized LASIK

A session titled Advances in Customized Refractive Treatments and Femtosecond Lasers in 2016 focused on using femtosecond laser technology with a number of other treatment options and discussed the advantages and disadvantages involved with each.

Parag Majmudar, MD, Chicago, highlighted Femtoflap for an Optimized LASIK. It has been 20 years since LASIK became mainstream, he said. Since that time, many changes have occurred. There has been a realization that ectasia is a major concern, there have been excimer laser technology advances from broad beam to flying spot to the current generation of lasers for faster and smoother ablations, and femtosecond technology has largely supplanted microkeratomes as the tool of choice. There are many advantages of being able to use the femtosecond laser, Dr. Majmudar said, including customizable flap parameters, like side cut angles, flap size, flap thickness, and flap shape. When using an acute angle side cut, there may be a higher incidence of flap slippage, he said, but femtosecond lasers allow the surgeon to make a customized side cut angle. Additionally, flap size is important, and femtosecond lasers can reproducibly create smaller diameter vs. larger diameter flaps. Smaller flaps may have less dry eye, but they could also result in higher order aberrations if not exactly centered.

You can also use the femtosecond laser to control flap thickness. Variability of microkeratome flaps is well documented. With femto flap thickness, the standard deviation is much smaller, he said.

The final parameter that we can customize is flap shape, Dr. Majmudar said, questioning if a round flap is really ideal for LASIK. The cornea is not round, he said, it is an ellipse. The average corneal size is 11 mm by 12 mm, so it may be better to have an ellipsoid flap. An advantage of an elliptical flap is that the majority of patients who will be treated have with-the-rule (WTR) astigmatism (requiring an elliptical ablation shape). He added that round flaps may rotate once they are in place, which could result in striae, whereas elliptical flaps only fit one way. There are also fewer lamellae severed. At this point in time, however, Dr. Majmudar indicated that he is still using round flaps.

The ultimate use of femto, he said, is as a customized non-excimer vision correction tool. He detailed the value of the small incision lenticule extraction (SMILE) procedure that many surgeons are gaining experience with (although more internationally than in the U.S. at this time). SMILE uses the femtosecond laser to create a small incision into the anterior stroma and a dissection in two planes to create a lenticule, which is then removed, he said. Potential advantages of this new procedure are fewer nerves affected, faster recovery of corneal sensation, and a potential biomechanical advantage. The extracted lenticule may also be extracted, Dr. Majmudar said, either with reimplantation for ectasia or return to myopia when presbyopic or for endokeratophakia.

Femtosecond lasers have allowed us to have a renaissance or rebirth of LASIK, he said. There is widespread use due to a better safety profile and the ability to create a customized and optimized LASIK experience.

Gaining efficacy by using the femtosecond laser and intracorneal ring segments

David Touboul, MD, Bordeaux, France, discussed Femtosecond and Intracorneal Ring Segment for a Gain in Efficacy. Performing the ring procedure with manual dissectors was sometimes difficult, he said. There were often inaccuracies in terms of centering, positioning, and depth, but the complication rate of ring implantation dramatically decreased with the use of the femtosecond laser, Dr. Touboul added. The femtosecond laser is the perfect tool to perform customized pre-cut patterns, he said. However, this technology still has its limitations. There could be tissue opacities, interface discontinuities, or corneal viscoelastic anisotropia. Other limitations that Dr. Touboul mentioned were that the femtosecond laser needs a reference plane, involving a window of applanation or imaging system, and it has very precise settings depending on the preoperative data and specific software. You need to be sure that many parameters are optimized for ring insertion, he said, like preop data, software settings, and surgery.

In the future, Dr. Touboul said that intraoperative aberrometry systems could be useful to compensate for comatic aberrations and astigmatism. He said that the femtosecond laser provides the opportunity to get rings accurately planed and inserted for a gain of efficacy. Ring insertion is still a handmade procedure, he said, and is very dependent on surgeon experience. There could be more predictable outcomes in the future with more research.

Pearls for anterior segment disease

From Acanthamoeba keratitis and fungal keratitis to ocular rosacea and ocular surface tumors, the session A Contemporary Review of Diagnosis and Treatment of Anterior Segment Diseases: Things You Dont Want to Miss covered a cornucopia of anterior segment disease topics.

Signs of Acanthamoeba keratitis include photophobia, tearing, pain, and, in the early stage, perineural infiltrates, said Ana Luisa Hfling- Lima, MD, So Paulo, Brazil.

Confocal microscopy can be a helpful way to view perineural infiltrates, she shared. Its important to see [perineural infiltrates] once so you never miss them again, she said.

Dr. Hfling-Lima encouraged attendees to review the ophthalmic journals for images of Acanthamoeba infection, so it will become easier to identify it in patients.

In later disease, ring infiltrates, ulcerations, and corneal edema are more common. Signs of severe disease can include abscesses, glaucoma, and corneal melt. There also may be scleritis that is unrelated to Acanthamoeba.

Although topical corticosteroid treatment is controversial, if a patient has been treated for Acanthamoeba for 2 weeks and still has persistent inflammation, it is OK to prescribe them, she said.

Fungal keratitis comes with its own set of diagnosis and treatment challenges, according to Guillermo Amescua, MD, Miami. While 5% to 20% of microbial keratitis cases can be fungal, at Bascom Palmer Eye Institute, it can be closer to 35%. The rate of fungal keratitis will vary geographically, Dr. Amescua explained.

Risk factors associated with fungal keratitis include trauma, agricultural work, previous surgery, contact lens use, and herpes simplex keratitis. In terms of helping to diagnose fungal keratitis, theres nothing better than a good scraping, Dr. Amescua said. Polymerase chain reaction and confocal microscopy are also helpful. Corneal biopsy can be performed, but it is hard to perform under a slit lamp, Dr. Amescua said. When sending out tissue samples, Dr. Amescua recommended sending half to microbiology and half to pathology to more effectively pinpoint the problem.

The most effective treatment Dr. Amescua and colleagues have found for fungal keratitis is natamycin. Surgery is also an option. Sometimes a surgical intervention is better than waiting for a severe case to develop, he said.

In the future, photodynamic therapy may play a stronger role in fungal keratitis treatment, but Dr. Amescua has not found it that successful so far.

Comprehensive approaches to eyecare to fight global visual impairment

There are 3.167 billion people around the world who have vision impairment at various stages, said Silvio Maniotti, MD, World Health Organization, Geneva, Switzerland. The most common causes of blindness are refractive errors, cataract, glaucoma, age-related macular degeneration, and diabetic retinopathy. At the same time, chronic eye disease requires a complex diagnosis, long-term follow up, and sophisticated equipment.

These factors led clinicians to come together in the session Comprehensive Eye Care or Disease Specific Approaches to discuss how to better identify and treat eye disease around the globe.

Gullapalli Rao, MD, India, discussed how the LV Prasad Eye Institute uses its clinics to treat cataracts. Even though care is provided for free to a large portion of cataract patients, the institute still finds that cataract treatment is effective and provides good cost recovery.

One problem that Dr. Rao and colleagues have found is the quality of training for residents; without such training they cannot work effectively within the community, he said.

Refractive errors are another common cause of blindness and visual impairment, said Kovin Naidoo, OD, South Africa. By 2050, there will be 5 billion myopes worldwide; this number will become larger compared with the current total due to an increase in near work.

To better treat refractive errors, clinicians must take into account advocacy, human resource training, sustainable delivery, and research.

One mistake to avoid is focusing only on the public sector; the private sector and social enterprises/nonprofits and NGOs play a role in expanding comprehensive eyecare to diagnose and treat refractive errors, Dr. Naidoo said.

Assessing and treating anterior segment trauma

Better education about eye injuries and the advocacy of protective eyewear during sports could go a long way in helping to avoid traumatic cataracts in children, said Angela Maria Hernandez, MD, Bogot, Colombia, during the session Management of Anterior Segment Injuries. There are 250,000 annual cases of pediatric traumatic cataract, which are a leading cause of monocular childhood blindness, Dr. Hernandez said. The injuries are more common in boys, as they are more likely to engage in eye-risky activities and sports, such as paintball.

Before dilation of these eyes, surgeons should assess the best corrected visual acuity, fixation reference, pupillary reflex, and iris, Dr. Hernandez advised. After dilation, surgeons should view the eye via slit lamp examination and check both the anterior and posterior segments. Dr. Hernandez shared a pearl for optimal IOL selection. Keep in mind that a myopic shift will happen, so do an undercorrection, she said.

Traumatic cataracts in adults are usually caused by blunt trauma, rupture, penetrating trauma, intraocular foreign bodies, or perforating trauma, said Carlos Restrepo, MD, Colombia. Common screening tools to better assess the trauma to the eye include X-rays, CT, MRI, optical coherence tomography, and ultrasound biomicroscopy. Dr. Restrepo usually uses X-rays but noted that the other more sophisticated equipment can be helpful if a surgeon has access to them.

Surgeons should consider the medico-legal issues associated with traumatic cataract and should make sure to 1) document a complete case description, 2) fully explain to patients the cause and effect of the injury and treatment, 3) note patient compliance to any recommended treatment (this is an area where Dr. Restrepo often finds problems), and 4) document the relationship between the cataract and trauma.

Cornea wounds from ocular trauma occur in half of all serious cases, said Santiago Garcia Arroyo, MD, Mexico City. A little more than 40% of these injuries occur at home; 52% are a full thickness laceration. When examining patients with corneal wounds, use external eyelid retractors to better view the eye but avoid putting pressure on the globe. If retractors are not available, Dr. Garcia Arroyo said that a bent paperclip can be used. If necessary, the patient can also receive a preservative-free anesthetic during this examination.

If there is a large self-sealing wound, Dr. Garcia Arroyo recommends use of a bandage contact lens, prophylactic antibiotic, and cyanoacrylate. If a practice does not have cyanoacrylate, an inexpensive alternative can be Kola Loka (known in English as Super Glue), found at local hardware stores, he said.

If there is a full-thickness non-self sealing wound, the surgeon must fix it as soon as possible.

In 40% of eye injuries, there are corneal foreign bodies, often caused by welding, hammering, or grinding. Sadly, we see a lot of workers who dont even know they should be using protective equipment, Dr. Garcia Arroyo said.

Satisfaction in refractive surgery

Ronald Krueger, MD, Cleveland, discussed quality of life after refractive surgery, specifically looking at satisfaction in physicians. How good is LASIK? he questioned. Modern day LASIK has 20/20 outcomes in greater than 80% of eyes and satisfaction in 95% of patients, he said. There are around 1 million eyes treated in the U.S. each year with LASIK, and the U.S. military has accepted it for its pilots. However, Dr. Krueger said an interesting take is to look at LASIK results among high performing professionals since physicians and surgeons might have higher demands and be more suspicious. Dr. Krueger did a study that surveyed all MDs receiving laser vision correction at the Cleveland Clinic by a single surgeon in the last 11 years (from 2000 to 2011). He looked at 429 eyes, and for the patient satisfaction survey, 226 patients were enrolled and emailed. Overall, there was a 58% response rate, Dr. Krueger said, with responses coming back from 132. Of these respondents, 28% were surgeons, 43% performed procedures that were not surgery, and 29% did not perform procedures or surgery. Questions in the survey asked the physicians to determine how satisfied they were with their procedure. The vast majority, 95%, were either satisfied or very satisfied with their vision without glasses or contact lenses, and 96% said that given their experience and outcome, they would repeat the procedure.

Compared to vision prior to surgery, 84.3% said that their quality of vision was better or much better than before. Thirty nine percent said that they were able to perform procedures better or much better than before. A high percentage, 90%, said their vision after refractive surgery has not limited their ability to work.

While there were a few troubling results, Dr. Krueger said that there were only 7 dissatisfied patients. Of these, 5 said they would not do the procedure again, while 2 said they would despite being dissatisfied.

Looking forward, he said these quality of life outcomes, although good, could be better. The study outlines the success of LASIK since its beginning, Dr. Krueger said, and it includes data with microkeratomes and conventional profiles. He indicated that he is continuing to look into results on this topic and is currently reviewing outcomes of physicians over the past 5 years with a single platform of wavefront-optimized femto LASIK. Despite their demands, physicians experience good outcomes, satisfaction, and quality of life improvements, Dr. Krueger said. Improvement in the quality of their work also leads to better patient care. Overall, his results show that refractive surgery among physicians is successful.

Latin America wins gold in WOC Olympics event

The 2016 Summer Olympic games in Rio de Janeiro, Brazil, may not be until later this year, but Latin America has already taken home the gold medalthat is, the gold medal for the inaugural Cataract Surgery Olympics: WOC Mexico. The lively, interactive session featured four teams representing four regions of the world: Latin America, North America, Europe/the Middle East, and Asia-Pacific.

Members of each team presented a challenging surgical case and discussed how they solved those challenges. A panel of judges1 from each regionrated each team on a scale of 1 to 5. In addition to the judges, the audience was able to vote on the surgeon who had the best teaching case and the best surgeon overall.

Team members wore colorful sports jerseys to represent their regionthe Latin American contingent even wore soccer (ftbol) shorts.

Ultimately, the Latin American teamfeaturing L. Felipe Vejarano, MD, Colombia; Eduardo Chvez, MD, Mexico City; Eduardo Soriano, MD, So Paulo, Brazil; and Luis Izquierdo, MD, Lima, Perutook home the gold medal for their presentations. Dr. Izquierdo also won the audience vote for best teaching case based on his presentation Trust Nobody, in which he performed cataract surgery on a 58-year-old female and inadvertently implanted a +16 D IOL that was not what the patient required. When the patient returned to surgery to have her lens explanted, Dr. Izquierdo checked the IOL that was about to be implantedonce again, it was the wrong one. By the time he received the right lens, a +5 D, and went to implant it, the lens haptic broke. Then, when the lens opened, posterior capsule rupture occurred.

Dr. Izquierdo demonstrated in his presentation how he handled this difficult case.

The silver medal went to the team from Europe/the Middle East, which included Boris Malyugin, MD, Moscow, Richard Packard, MD, London, Maria-Jose Tassignon, MD, Antwerp, Belgium, and Yehia Salah El Din, MD, Cairo, Egypt.

The bronze medal was awarded to the North American team, which included Ike Ahmed, MD, Toronto, Samuel Masket, MD, Los Angeles, Sonia Yoo, MD, Miami, and George Beiko, MD, St. Catharines, Canada. Dr. Ahmeds presentation of a case involving iridodialysis and pupil repair won the audience award for best surgeon.

Also competing in the Olympics session was the Asia-Pacific team featuring Gerard Sutton, MD, Australia, Mohan Rajan, MD, India, Arup Chakrabarti, MD, Thiruvananthapuram, India, and Tetsuro Oshika, MD, Tokyo, Japan.

David Chang, MD, San Francisco, and Abhay Vasavada, MD, Ahmedabad, India, moderated the inaugural Olympics session.

Latin American ophthalmologists, researchers aim to reach more visually impaired patients

Latin American ophthalmologists must grapple with the changing challenges of blindness and visual impairment, particularly among poorer regions, said speakers at The Challenge of Screening, Treating, and Training for DR, Glaucoma and AMD in Latin America. The prevalence of blindness in Latin America is 0.7% to 3% depending on the country, said Juan Carlos Silva, MD, Bogot, Colombia, of the Pan-American Health Organization and World Health Organization. The leading causes of blindness are cataracts (44% to 63%), glaucoma (10% to 15%), and diabetic retinopathy (0% to 16%), Dr. Silva reported. As one might expect, blindness and visual impairment are more likely to affect poorer people with lower levels of literacy and education, Dr. Silva said. However, some countries, such as Paraguay, have made progress in their treatment for patients with eye disease.

One change the researchers have seen in recent years is the growth in diabetes, which can obviously affect the eyes as well. Some challenges in the coming years will be the changing epidemiological profile of blindness/visual impairment, strengthening the public sector to reach the poor, and getting more ophthalmologists into rural and other areas. There are still areas that dont have any ophthalmologists, which is incredible, Dr. Silva said in Spanish.

Programs must also focus on incorporating eyecare throughout the continuum of life, including neonatal care, school health, and among adults, he said.

Enrique Graue-Hernndez, MD, Mexico City, outlined the 10 strategies used by the Prevention of Blindness Committee in Mexico. The committee, which began in 2009, plays an advisory role in helping to treat eye disease as 80% of blindness causes can be prevented, said Dr. Graue-Hernndez, citing information from the World Health Organization.

Some strategies used by the committee include the creation of a National Registry System of Ocular Diseases, screening of refractive errors in children, screening for retinopathy of prematurity, and improving the National Registry of Corneal Transplants. One trend the committee has seen is the growth of diabetes in Mexico, which now affects a sizable chunk of the population. Although better diabetic retinopathy screening is a goal of the committee, such screening is currently suboptimal, Dr. Graue-Hernndez said.

Pedro Gmez Bastar, MD, Montemorelos, Mexico, focused on the results of population-based rapid assessment of avoidable blindness studies in Mexico and presented data from 3 analyses, 2 done in the state of Nuevo Leon in 2005 and 2014 and 1 done in Chiapas in 2015. Two of the studies have results published in the British Journal of Ophthalmology. The third is in the process of being published.

The studies revealed a blindness prevalence of 1.5% in Nuevo Leon and 2.3% in Chiapas. Blindness from cataract was 32% in the most recent Nuevo Leon study and 63% in the Chiapas study. The prevalence of diabetic retinopathy was 16.3% in Nuevo Leon versus 36.2% in Chiapas; the lower number in Nuevo Leon is likely due to better access to care and medicines, Dr. Gmez Bastar said.

The studies identified better quality cataract care at charity and private hospitals compared with government hospitals.

With 20% to 30% of diabetics having diabetic retinopathy and a rise of type 2 diabetes in Mexico, further analyses must focus on tracking and preventing these health problems.

Going forward, clinicians and researchers should also consider how to improve the quality of cataract surgery and how to reduce its cost, Dr. Gmez Bastar said.

Tips for using CTRs

In IOL Fixation with Deficient Capsular Support, Alan Crandall, MD, Salt Lake City, shared the original information on capsular tension rings (CTR).

CTRs were designed to maintain the capsules contour and stretch the posterior capsule when there is zonular dehiscence or a rupture occurs after blunt or penetrating injury or surgical trauma, he said, or when inherent zonular weakness is present. The original CTR came in a number of different sizes, Dr. Crandall said.

The CTR can be inserted at any point during the surgery depending on what your surgical need is at the time, he added. To insert the CTR, a Geuder injector or manual insertion may be used. Grieshaber iris hooks may be needed to suspend the bag prior to insertion of the CTR, Dr. Crandall said. Additionally, slow motion phaco is necessary, and cortical cleanup may be more difficult in the presence of a CTR. A Cionni CTR requires suture fixation with 9-0 prolene or GORE-TEX, he added. A complete cortical cleaving hydrodissection and removal of the anterior cortex with I/A is necessary if placing a CTR prior to phaco, Dr. Crandall said. There are a number of instances where a CTR may be appropriate. These indications include with pseudoexfoliation, high myopia, previous ocular trauma, post vitrectomy, previous glaucoma filtration surgery, previous RK, and intraoperative zonular damage. In terms of the mechanism of the CTR, Dr. Crandall said the ring diameter is greater than the capsular bag. This puts the force on the fornix, he said, and distributes focal forces circumferentially. This facilitates surgery and promotes early and late IOL centration.

Dr. Crandall offered clinical tips for inserting the ring. Fractionate the anterior chamber with viscoelastic, he recommended. If you have known areas of weakness, its better to start your tear toward the area of weakness, he said. If you go toward the defect, youre utilizing the good zonules, Dr. Crandall added. On an average day, he might use 5 to 6 CTRs.

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