September 2018


EyeWorld reports from the 2018 APACRS annual meeting

EyeWorld reports from the 2018 APACRS annual meeting, July 19–21,
Chiang Mai, Thailand

View videos from the 2018 APACRS:

Li Lim, MD, discusses the role of ocular surface disease in the
management of refractive cataract surgery patients.

View videos from the 2018 APACRS:

Michael Lawless, MD, discusses the advantages and disadvantages of the SMILE technique for keratorefractive surgery.


Cataract surgery and the retina

A symposium presented by the Thai Retinal Society (TRS) featured various presentations relating to cataract surgery and the retina. 
Tharikarn Sujirakul, MD, Bangkok, Thailand, presented “All You Need to Know about Cataract Surgery in Retinal Dystrophy.”
She said that the impact of cataracts in retinal dystrophy patients is well known, and these patients may be more sensitive to lens opacity compared to normal patients. Higher intraocular light scattering can also occur, as well as compromised photoreceptor function.
Dr. Sujirakul said some of the main concerns are if the patient’s vision will improve, if the cataract will quicken RP progression, and if there will be phototoxicity.
Will the patient’s vision improve? Dr. Sujirakul said it will. There is significant visual improvement in terms of visual acuity or subjective vision in all patients, and patients with intact central ellipsoid line have a better postoperative visual outcome. 
Will the cataract surgery quicken RP progression? It won’t, Dr. Sujirakul said, adding that there is no difference in RP progression rate detected by spectral domain OCT or other function tests. 
She said that phototoxicity is also unlikely. There has been no worsening of vision or direct phototoxicity reported with the current surgical procedure. 
These patients may have a higher rate of zonular compromise and IOL subluxation. This can be detected in the preoperative, perioperative, and postoperative period. Additionally, chronic inflammation and increased inflammatory cytokines can cause this. 
Patients also have a higher incidence of rapid capsular contraction syndrome, and some cases are reported as early as 2 weeks postop. 
Higher incidence of posterior capsular opacification (PCO) may also be a concern. Dr. Sujirakul said that 40–50% of patients require a YAG capsulotomy. This occurs more frequently with PMMA and silicone IOLs compared to acrylic material. 
These patients may have more visually significant postop CME, which may be caused by preexisting epiretinal membrane. 
Dr. Sujirakul shared some of the preoperative considerations for these patients. Careful examination to detect zonular instability is important to plan surgery well, she said. Treating preexisting conditions that might limit a promising outcome is also important. 
Dr. Sujirakul highlighted IOL selection for these patients. In terms of focality, a monofocal may be preferred to a multifocal. Most papers advise to choose a monofocal to avoid light scatter, she said, as the photoreceptor may be compromised.
She said that acrylic material is preferred to PMMA or silicone, and a three-piece lens is generally preferred to a one-piece. In terms of choosing a clear vs. yellow tinted color, Dr. Sujirakul said that the trend is to use more yellow, but there is no solid evidence. She also said to aim for plano or myopia. 
Important intraoperative considerations include minimizing phototoxicity, minimizing stress on the zonules, and making every effort to prevent capsular contraction syndrome and posterior capsular opacity. 
Dr. Sujirakul detailed how to minimize capsular contraction syndrome. This includes larger ACC size (at least 5.5 mm), meticulous ACC polishing, using a three-piece IOL, possibly using a capsular tension ring, using multiple radial relaxing incisions, and good control of postoperative inflammation. 
Postoperative considerations include being more aggressive in inflammation control to avoid PC, capsular contraction syndrome, and IOL subluxation. Early detection of CME is important, and if there is CME, you can use topical steroids, NSAIDS, or local steroid injections. Low vision rehabilitation might be needed in some patients.

Cataract surgery in uveitis

Cataract surgery in uveitis was the topic of a symposium presented by the Thai Ocular Immunology and Inflammation Society (TOIS). During the session, Wantanee Sittivarakul, MD, Songkhla, Thailand, discussed preoperative evaluation in these cases. 
Cataract is a common complication of uveitis, she said. “It’s almost never a routine surgery in uveitic eyes,” Dr. Sittivarakul said. It requires a detailed preoperative assessment, is often technically complex intraoperatively, and there may be uncertainty of the postoperative course. She presented important points to consider preoperatively. 
First, establish an accurate diagnosis of uveitis. To do this, obtain appropriate medical history and labs and define uveitis by course, laterality, and anatomic location. Different diagnoses have different prognosis, and infectious uveitis must be identified and treated. 
It’s important to determine the need for cataract surgery. Indications for cataract surgery include visually significant cataract in eyes with good potential for improved vision, lens induced intraocular inflammation, and poor view of the fundus for examination or posterior segment surgery. She also said to determine whether or not the cataract is responsible for the patient’s visual loss. 
Dr. Sittivarakul stressed the importance of doing a complete ophthalmic evaluation. This includes assessing the visual potential and coexisting ocular problems, as well as doing an assessment of other conditions that affect surgical planning. 
The timing of the surgery is important. Dr. Sittivarakul said preoperative inflammation control is crucial for a good outcome. Quiescence of uveitis for a minimum of 3 months prior to surgery is important. But if this is not possible, do the surgery when the inflammation is maximally suppressed and stable. Immunomodulatory therapy may be required to achieve a sustained quiescence, she added.
Next, Dr. Sittivarakul stressed preoperative steroid prophylaxis. Increase steroid dosage briefly before surgery as a prophylaxis against surgically induced inflammatory relapse. She also said that an immunomodulatory agent stays unchanged prior to surgery in those who’ve been using it as a maintenance for uveitis. The regimen of steroid prophylaxis depends on the diagnosis/course of patients’ underlying uveitis, Dr. Sittivarakul said. 
Her next consideration related to the IOL. An IOL is not contraindicated with optimum control of inflammation preoperatively, but pediatric use may be controversial. In-the-bag placement is always preferred, Dr. Sittivarakul said, and acrylic IOLs and heparin surface modified PMMA IOLs performed better than non-heparin surface modified PMMA and silicone IOLs in study. 
Silicone IOLs should be avoided in patients who may require vitreoretinal surgery in the future, and a multifocal IOL might be a poor choice in chronic uveitis. 
Her final point was to counsel patients with uveitis who are undergoing cataract surgery. They will need to know that increased medication dosage in the perioperative period may be required, and it is a more complicated surgery with prolonged surgical duration. Additionally, patients should beware of significant postoperative inflammation and delayed visual recovery.  Medication adherence is important. They will need more frequent visits, and there is a chance they will have to undergo additional procedures. 

Neuroimaging for ophthalmologists

During a symposium presented by the Thai Neuro-Ophthalmology Society (TNOS), physicians shared information on neuroimaging for ophthalmologists. During the session, Nattapong Mekhasingharak, MD, Phitsanulok, Thailand, presented “I See Two of You! My Cataract Keeps Bothering Me!” He shared a case of an 87-year-old woman who developed double vision for 2 weeks. Her double vision would disappear when either eye was covered. She also had hypertension that was well controlled.
When evaluating a patient with a complaint of double vision, Dr. Mekhasingharak said that the first question to ask is if the diplopia is monocular or binocular. Monocular diplopia is an optical abnormality associated with uncorrected refractive error, cataract, corneal surface irregularity, iris hole, or dislocated lens, he said. 
However, this patient’s double vision would disappear when either eye was covered, so she had binocular diplopia. Binocular diplopia is caused by ocular misalignment.
The diagnosis for this patient was partial third cranial nerve palsy with pupillary involvement. There may be numerous causes of third nerve palsy. She underwent emergency MRI and MRA but did not have cataract surgery.
Kittisak Unsrisong, MD, Chiang Mai, Thailand, noted that MRI is tricky because you have to specify what you’re going to look at (the brain, the vessel, the cranial nerve, etc.). The clinical history is important for this, and without it, you could miss the abnormality. 
Dr. Mekhasingharak said that the patient was admitted to the neurosurgical ward, but she refused to get any further intervention after discussing risks and benefits. Two months later, the patient’s symptoms improved, and 5 months later, she had no diplopia in primary position and had light limitation of upward and downward movement in the right eye.
Dr. Mekhasingharak said that third cranial nerve palsy with pupillary involvement must urgently undergo vascular imaging because of the risk of aneurysm.

APACRS annual meeting kicks off with opening ceremony 

The APACRS annual meeting opening ceremony featured welcome addresses by Pannet Pangputhipong, MD, Bangkok Thailand, organizing chairman of the meeting, Prof. Emeritus Piyasakol Sakolsatayadorn, Minister of Public Health of Thailand, and Ronald Yeoh, MD, Singapore, APACRS president.
During his welcome address, Dr. Yeoh stressed the value of the Barrett Online Calculator, created by Graham Barrett, MD, Perth, Australia. The calculator is available online for free, and Dr. Yeoh noted that it gets around 50,000–100,000 clicks per day and has helped countless surgeons and patients. “Before I step down as the president, I want to thank Graham once more for giving this wonderful calculator to the world,” he said. 
“Thank you for entrusting me with the presidency of APACRS, which has been the highlight of my career,” Dr. Yeoh said, adding that Hiroko Bissen-Miyajima, MD, PhD, Tokyo, Japan, will be the next APACRS president. “I’m sure she will take APACRS to new and greater heights,” he said.


The APACRS LIM Lecture was presented by Eric Donnenfeld, MD, Rockville Centre, New York, on the topic of “Refractive Surgery Comes of Age: How Good is LASIK? The Myths, Misconceptions, and Reality.”
In spite of LASIK’s long clinical and historical presence, misconceptions about the risks and benefits of this procedure persist, Dr. Donnenfeld said. He shared six myths and misconceptions of LASIK:
1. Physicians would not have LASIK on their own eyes. 
2. The long-term effects of LASIK are not known. 
3. Contact lenses are safer than LASIK. 
4. LASIK significantly increases the risk of a patient having glare and halo. 
5. The safety and efficacy of LASIK has not improved over time. 
6. Dry eye is extremely common following LASIK. 
Dr. Donnenfeld detailed the history of LASIK, starting with the clinical trial and its approval. One of his first papers on LASIK looked at the effect on dry eye, and he learned that it does cause dry eye. Statistically, dry eye returns to normal at 6 months following surgery.
Dr. Donnenfeld discussed patient dissatisfaction with LASIK, noting an FDA hearing addressing the topic. In addition to speaking in favor of LASIK at the hearing, Dr. Donnenfeld said he learned a lot by listening to patient testimony. The most common problem that made patients unhappy was the sense of abandonment from the surgeon when they didn’t get the results that they wanted. 
An early problem of LASIK was ablation decentration, which can be addressed with pupil tracking and other technologies. The problem of PRK corneal haze has almost completely been resolved with the use of mitomycin-C. Meanwhile, flap complications have been addressed with the advent of the femtosecond laser and better microkeratomes. Glare and halo can be remedied with blend zones, customized ablations, and optimized ablations, Dr. Donnenfeld said. He noted that the problem of ectasia is addressed with better diagnostic equipment and patient selection, as well as crosslinking.
In his conclusion, Dr. Donnenfeld again referenced the “myths and misconceptions” about LASIK: Physicians have among the highest prevalence of having undergone LASIK of any occupation; LASIK has more than a 20-year track record, and long-term studies have shown refractive stability and safety; daily wear contact lenses are likely less safe than LASIK when worn for 30 years, and extended wear contact lenses are definitely less safe than LASIK when worn for 30 years; modern LASIK improves glare and halo for the majority of patients, and there are a minority of patients who will develop glare and halo who did not have symptoms preoperatively; LASIK is the safest procedure with the greatest satisfaction of any surgery performed in the world today, and the safety and efficacy have improved markedly over the last 20 years and will continue to improve with technology advances; and dry eye is common after LASIK for the first 3 months, but it usually resolves after 6 months. 
Moving forward, the goal is continued improvement of patient satisfaction and 100% of patients seeing the same or better following LASIK than prior to surgery. “We need to embrace patients who are dissatisfied with their vision following LASIK and never allow them to feel abandoned,” Dr. Donnenfeld said.

CSCRS symposium

The Combined Symposium of Cataract and Refractive Societies (CSCRS) highlighted “Inner Focus – Innovative IOL Technology.”
Fritz Hengerer, MD, PhD, Heidelberg, Germany, discussed the Light Adjustable Lens (LAL, RxSight, Aliso Viejo, California), which he described as a three-piece silicone IOL with unique options in order to change the refraction noninvasively after surgery. After wound healing, you can do the first refraction and see what results were obtained and how far the patient is from target refraction. The adjustments are made using UV light. Patients receiving this technology are clearly informed about the technology and drawbacks, Dr. Hengerer said, stressing the importance of patients wearing UV-protecting glasses after surgery while the IOL is still being adjusted.
This lens has now been commercially available for 10 years in Europe. There are several options to optimize VA for distance, intermediate, and near, and adjustments are noninvasive. When the lens is “locked in,” patients no longer have to wear their protective spectacles.
Dr. Hengerer noted that the LAL is available for up to 3.0 D of astigmatism and for post-refractive surgery patients and presbyopia correction. He stressed that compliance is one of the keys to success.
Dr. Hengerer said that there may be some limitations with the LAL. For example, small pupils or corneal scars do not allow UV light to go into the LAL. He would not use it with a CTR, would not fixate the lens in the sulcus, and would not utilize it for pediatric cases.
Liliana Werner, MD, PhD, Salt Lake City, presented on a possible new indication for the femtosecond laser: IOL power adjustment. This involves a laser-induced chemical reaction in a targeted area of the IOL optic substance, and it involves localized increase in hydrophilicity and decrease in refractive index. Simultaneously, the laser builds refractive index shaping lens within the targeted area. 
This technology was developed by Perfect Lens (Irvine, California) and uses green light, low energy levels, and can be used with commercially available IOLs.
Dr. Werner said that the IOL power adjustment by femtosecond laser can be used with hydrophobic or hydrophilic acrylic IOLs. It’s noninvasive, fast, and can be done under topical anesthesia, and multiple adjustments are possible.

Sunrise Lectures

Kimiya Shimizu, MD, Tokyo, Japan, presented “How to Avoid Dysphotopsia,” and detailed a study he did to investigate risk factors for dysphotopsia after cataract surgery by a multivariate analysis. His study included 213 eyes of 213 patients. Inclusion criteria included postop CDVA of greater than or equal to 20/20, same IOL material for both eyes, and in-the-bag fixation. Exclusion criteria included patients with corneal or retinal disease, those who had undergone corneal refractive surgery, and multifocal IOL implantation, among others.
Dr. Shimizu discussed a postoperative questionnaire used in his study to ask patients about their satisfaction after cataract surgery.
He described the logistic regression analysis done to look at dysphotopsia. In the study, 26.8% of patients had dysphotopsia; 24.4% had positive and 4.2% had negative. He found that factors relating to all dysphotopsia were age and IOL material. Positive dysphotopsia was related to IOL material, and negative dysphotopsia was related to age, axial length, and IOL material. 
Risk factors for negative dysphotopsia include both primary and secondary factors, Dr. Shimizu said. Primary factors are a smaller photopic pupil, larger positive angle kappa, the shape of IOL, nasal anterior capsule overlying anterior nasal IOL, high dioptric power if eqi-biconvex or plano-convex, and the optic-haptic junction of the IOL not being horizontal. Secondary factors include edge design, material of the IOL, and negative aspheric surface. 
Dr. Shimizu said that to treat dysphotopsia, physicians can use IOL exchange, piggyback IOL implantation, or reverse optic capture.
Liliana Werner, MD, PhD, Salt Lake City, discussed “Causes of IOL Opacification Requiring Explantation.” She spoke about hydrophilic acrylic lenses and noted that the leading cause of opacification is calcification. It may present on the surface of the lens. 
Dr. Werner shared a study she did looking at this problem in several different IOLs. She said that this is a multifactorial problem, and she highlighted the role of IOL packages with silicone compounds, phosphate-buffered ophthalmic viscosurgical device, local conditions of calcium/phosphate supersaturation in the vicinity of the IOL surfaces or within their substance, and conditions with chronic breakdown of the blood-aqueous barrier. 
You have to know how to make the diagnosis of calcification during slit lamp examination, Dr. Werner said. She added that further investigation is necessary to determine if localized calcification is a result of direct contact between the IOL surface and exogenous gas/substance, metabolic change in the anterior chamber due to the presence of exogenous gas/substance, or exacerbated inflammatory reaction after multiple surgical procedures. 
Gerd Auffarth, MD, Heidelberg, Germany, presented “Preloaded Systems: Ins and Outs.” Dr. Auffarth discussed clinical ease of injection, complications of injector systems, injector force analysis, and damage to injector systems. He noted complications that could occur relating to haptics, particularly when they are sticking together or sticking onto the anterior surface.
Based on studies looking at different preloaded systems, Dr. Auffarth had several conclusions. Implantation and unfolding behavior among hydrophobic IOLs revealed large variability.
He added that haptic adhesions to the optic can be of clinical significance, especially in complicated cases. Injector force pushup systems vary among contemporary preloaded systems, Dr. Auffarth said, and improvement of injector systems reduces the damage of the plunger/cartridge to the IOL. 

Finding the Right Path: Predicting Outcomes in Cataract Surgery

Cataract surgery has moved from being a rehabilitative surgery to a refractive surgery. As such, “it is my firm conviction that the same philosophy should be extended to glaucoma patients who need cataract surgery,” said Arup Chakrabarti, MD, Trivandrum, India. However, there are special considerations that should be taken into account when selecting an IOL and calculating a power. 
Trabeculectomy can induce with-the-rule corneal astigmatism, and after successful trabeculectomy, when the IOP comes down, there can be a decrease in axial length. There can be an increase in axial length in post-trab eyes after cataract extraction (a myopic shift) and a decrease in axial length in post-trab eyes after phaco (hyperopic shift). 
When it comes to premium lenses, there is little in the published literature about the role of multifocal lenses in glaucoma patients. However, Dr. Chakrabarti pointed out, patients with moderate to advanced glaucoma can have reduced contrast sensitivity and a decrease in other visual functions. These conditions could exacerbate some of the optical issues associated with multifocal lenses, such as dysphotopsias and optical aberrations. Though he would not recommend a multifocal lens for a patient with advanced glaucoma—recommending monovision with an aspheric lens instead—he would consider these IOLs for glaucoma suspects, patients with ocular hypertension, and those with mild glaucoma who are stable and controlled with no signs of progression. 
Dr. Chakrabarti said he regularly implants toric IOLs in glaucoma patients but noted that he avoids them in patients having a combined phaco/trabeculectomy procedure due to the with-the-rule astigmatic shift that can be seen postoperatively. 
Dr. Chakrabarti noted the impact of the ocular surface on multifocal and toric IOLs. With the majority of glaucoma patients having some degree of ocular surface disease, the issue needs to be diagnosed and managed before using one of these lenses. 

Top cataract surgery tips

The final session of the APACRS annual meeting was “Achieving Nirvana,” which featured presenters sharing surgical tips and maneuvers that attendees could take home and use in practice.
Eric Donnenfeld, MD, Rockville Centre, New York, spoke about nuclear chips in the vitreous after cataract surgery and how to prevent these. Nuclear chips can sometimes be found floating in the back of the eye and can cause inflammation after surgery. 
How do they get into the vitreous? When you’re using a phaco probe and move it to one side, it occludes the irrigation on one side, Dr. Donnenfeld said. It creates irrigation flow that pushes things through the zonules and into the posterior chamber, and he said that 25% of patients who have cataract surgery today can be found to have these chips. 
To avoid this, Dr. Donnenfeld offered several tips. You can keep your phaco tip open and central. You can make the incisions a little larger, so it doesn’t occlude irrigation to the side. There are also new designs for phaco irrigation sleeves that have little elevations to prevent occlusion of flow to the side. 
Pannet Pangputhipong, MD, Bangkok, Thailand, shared techniques for minimizing discomfort in high myopic eyes during phacoemulsification. This discomfort may be caused by sudden change in IOP or if the bottle height is too high.
The key solution, he said, is “slow motion irrigation.” The first technique Dr. Pangputhipong suggested for doing this is slow tip insertion: Use continuous irrigation; slowly insert the phaco or I/A tip; and allow the AC to inflate slowly. 
He also suggested pinching the irrigating line, adjusting the bottle height (lowering it to 30 cm and slowly raising it up), or using low phaco parameters.

EyeWorld reports from the 2018 APACRS annual meeting EyeWorld reports from the 2018 APACRS annual meeting
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