October 2018


EyeWorld reports from the 2018 Combined Ophthalmic Symposium

EyeWorld reports from the 2018 Combined Ophthalmic Symposium (COS), August 24–26,
Austin, Texas

View videos from COS 2018: EWrePlay.org

Leela Raju, MD, discusses logistics of including crosslinking in a clinical practice.

View videos from COS 2018: EWrePlay.org

Alan Crandall, MD, makes the case for small incision cataract surgery in developing countries.


Cataract surgery: upping your game

The first session of the program covered a variety of cataract surgery topics. Jonathan Rubenstein, MD, Chicago, shared pearls for dense and white cataracts.
When dealing with dense brunescent cataracts, Dr. Rubenstein stressed that you need adequate pupil dilation and to protect the cornea. 
He suggested a technique beginning with bowling out the superficial cortex/nucleus. Use a chopping technique (vertical and/or horizontal) and use a capsular tension ring if needed. Dr. Rubenstein added that the femtosecond laser may be helpful in these cases to get through the lens, but you may not be able to get adequate OCT imaging. 
Surgeons may encounter different types of white cataracts. These could include a white lens with a hard nucleus, white cortical cataracts with cortical-capsular adhesions and dense PSC and/or ASC, a partially liquefied intumescent swollen cataract, or a liquefied morgagnian cataract. 
Dr. Rubenstein suggested several techniques for managing white cataracts. Lower the pressure preop and decompress the capsular bag. Using trypan blue dye, using extra viscoelastic to keep pressure on the anterior capsule, using a slower and smaller capsulorhexis, rocking the lens gently during hydrodissection to release fluid from behind the lens, and using a horizontal chop or stop and chop phaco are helpful techniques in these cases.

Editors’ note: Dr. Rubenstein has financial interests with Alcon (Fort Worth, Texas) and Shire (Lexington, Massachusetts).

Glaucoma diagnostics, medical and surgical management

Thomas Patrianakos, DO, Chicago, offered several tips on visual field interpretation: know your reliability indices, use the global indices, recognize glaucomatous scotomas, be familiar with common artifacts and testing errors, and be able to correctly determine progression. 
Dr. Patrianakos discussed tips for RNFL and optic nerve exam. He described his step-by-step approach looking at signal strength, RNFL thickness/deviation map, TSNIT graph/quadrant analysis, tomogram, and tabular data. 
He noted that in terms of signal strength, 7 or greater is a good scan, but less than that could lead to falsely thin measurements. He also described some of the aspects of RNFL thickness maps and deviation maps and what they show, as well as the TSNIT graph, where RNFL thickness is overlaid on an age-related normative data background.
Dr. Patrianakos noted that there may be an average of 0.2 μm/year change in RNFL. 
During his presentation on “Making Sense of MIGS,” Thomas Samuelson, MD, Minneapolis, described why he approaches glaucoma surgery the way he does. 
Dr. Samuelson thinks that the risk of glaucoma surgery should not exceed the disease risk, and he prefers to retain normal physiology when feasible. He will also exercise caution with high outflow, low resistance pathways. 
Dr. Samuelson said it’s important to utilize diagnostic precision; you need to estimate disease velocity. Communication is key, especially in letting the patient know that no procedure can cure glaucoma and there is no one procedure that is the safest and most effective.
In another presentation, Dr. Patrianakos discussed some of the factors that help him choose which procedure to use for glaucoma patients. He stressed the importance of becoming comfortable with the procedures, knowing specific indications, safety and efficacy, how a procedure fits with your practice, and the expense. 
Dr. Patrianakos stressed the importance of knowing how to perform intraoperative gonioscopy, mastering one procedure (which he said makes it easier to incorporate other procedures), not giving up after your first adverse outcome, and reaching out for support. 
Dr. Patrianakos highlighted practice fit and tailoring procedures to your practice needs. For mild/moderate, well-controlled glaucoma, a trabecular meshwork (TM) stenting procedure may be appropriate. For moderate/severe glaucoma, he suggested TM ablations, suprachoroidal, or subconjunctival procedures. For a glaucoma practice, he suggested being comfortable with all MIGS and traditional glaucoma procedures.

Editors’ note: Dr. Patrianakos has no financial interests related to his comments. Dr. Samuelson has financial interests with a number of ophthalmic companies.

Premium cataract surgery

Tal Raviv, MD, New York, shared his five steps to toric IOL success. He first stressed the importance of accounting for posterior corneal astigmatism and mentioned that using the Barrett toric calculator can help with this. There is less with-the-rule and more against-the-rule than anterior measurement indicates, so you should undertreat with-the-rule and overtreat against-the-rule. 
Next, Dr. Raviv recommended setting surgically induced astigmatism (SIA) to 0.1 D. Accuracy increases by using temporal corneal incision on all patients, he said, adding to use a centroid value of 0.1 D in toric calculators. 
Dr. Raviv’s third step was to recognize long-term astigmatic drift. With-the-rule will drift to against-the-rule in all eyes at an average rate of 0.34 D per decade. 
He said that axis flipping can be a tool, and you should target the lowest cylinder while keeping long-term drift in mind. It’s better to flip from against-the-rule to with-the-rule since it will drift back, he said. 
Dr. Raviv said refractive cylinder is a clue. In older patients, when the refractive cylinder against-the-rule is larger than the corneal cylinder, you have to treat that. 
During her presentation on astigmatism management in challenging cases, Kendall Donaldson, MD, Plantation, Florida, highlighted what she considers the five most challenging cases of astigmatism management: pre-existing corneal conditions, keratoconus, history of penetrating keratoplasty (PK), history of corneal refractive surgery, and presbyopia astigmatism correcting IOLs. 
Pre-existing corneal conditions may include ocular surface disease, anterior basement membrane dystrophy, or Salzmann’s degeneration, Dr. Donaldson said, stressing the need to look at topography and Placido images as well as tomography.
Dr. Donaldson said that when dealing with keratoconus, you can use toric IOLs in some of these patients: those with mostly regular astigmatism, when there is significant improvement with refraction, if the patient is able to wear glasses with improvement some of the time, with stable Ks, and for patients with reasonable expectations. 
For those patients with a history of PK, Dr. Donaldson said you want to try to have all sutures removed before CE/IOL, want residual stable regular astigmatism, want a healthy graft, and want a reasonable patient. Some concerns for these patients are that the astigmatism may change with time, and astigmatism will change if the graft is repeated.
Dr. Donaldson highlighted some features of a good toric candidate after prior corneal refractive surgery: primarily regular, stable, repeatable astigmatism, minimal OSD, old records, reasonable expectations, no signs of progression or corneal steepening over time, and no signs of unstable vision throughout the day. 
She concluded with some of her pearls for astigmatism correction in complex cases, which included advising patients of inaccuracies/limitations, using multiple measurements and looking for consistency, being aware of OSD, and being aware of premium IOLs.

Editors’ note: Drs. Donaldson and Raviv have financial interests with a number of ophthalmic companies.

Pearls in cornea and refractive surgery

Terry Kim, MD, Durham, North Carolina, presented on corneal edema after cataract surgery, highlighting several causes: dense brunescent cataracts, Fuchs’ endothelial dystrophy, and retained lens fragments.
Dense brunescent cataracts, Dr. Kim said, are very dense in nature, with a large endonucleus/minimal epinucleus and cortex. The posterior epinucleus becomes firm, adherent, and difficult to fracture due to bridging posterior lens fibers, and there is resistance of the posterior nucleus to full cleavage regardless of the phaco technique. Dr. Kim added that it is most apparent in the posterior aspect of the central nucleus, resulting in the inability to engage the apex of the nuclear fragment in the phaco tip. 
For these cases, Dr. Kim advocated for using the miLOOP device (Iantech, Reno, Nevada).
When doing cataract surgery in patients with Fuchs’ endothelial dystrophy, Dr. Kim suggested several surgical strategies: dispersive viscoelastic, surgical maneuvers, phaco power modulation, efficient I/A, IOL considerations, and FLACS/other devices.
He stressed the use of dispersive viscoelastic and phaco power modulation. He noted that ultrasound power modulation can offer increased efficiency of torsional ultrasound, greatly reduced repulsion, decreased turbulence, enhanced followability, less risk of thermal burns, and less endothelial trauma. 
Lastly, Dr. Kim highlighted retained lens fragments in cataract surgery, and he said it might be best to viscodissect the fragment, bringing it up to the wound and burping the fragment out. Dr. Kim said if you go in with an I/A tip, it could flush the fragment out and sometimes into the iris, and you might not be able to find it. 

Editors’ note: Dr. Kim has no financial interests related to his comments.

Ocular surface management

Elizabeth Yeu, MD, Norfolk, Virginia, gave an update on management of the ocular surface and discussed current options and those in the pipeline. She first noted that it’s less common to have purely aqueous deficiency; meibomian gland dysfunction is involved in greater than 80% of dry eye disease. There are targeted strategies based on disease severity and etiology, and she said to treat both signs and symptoms.
Dr. Yeu highlighted options such as lubricants, nutrition, anti-
inflammatory agents, and amniotic membrane. She briefly touched on lid margin disease management and some new investigational approaches in artificial tears, neurostimulation, and anti-inflammatories.
Mitchell Weikert, MD, Houston, discussed the different types of amniotic membrane and applications. You can use amniotic membrane for non-healing corneal epithelial defects (neurotrophic keratopathy, recurrent erosions, bullous keratopathy, exposure keratopathy), chemical or thermal injuries, Stevens-Johnson syndrome/ocular cicatricial pemphigoid, infectious keratitis/corneal ulcers and perforation, ocular surface disease and dry eye, and ocular surface reconstruction, he said.
Dr. Weikert noted that physicians should pay attention to the coding when using amniotic membrane. 

Editors’ note: Dr. Yeu has financial interests with a number of ophthalmic companies. Dr. Weikert has no financial interests related to his comments.

Challenges, tricks, and musings

The final session of the meeting featured presentations on a variety of topics. One topic highlighted by Leela Raju, MD, New York, was outreach and opportunities to get involved. Affordability and accessibility are the goals, she said, adding that much of her outreach work has been focused on children. She mentioned the value of preventative ophthalmology, including school screenings. Dr. Raju stressed that it’s important to remember to work within the limits of that location, not just when doing surgery but also making sure the patient will be able to receive the follow-up necessary. When doing outreach work in other countries, you may find yourself outside your wheelhouse. Many locations don’t have subspecialty access, and telemedicine could be a good option.
M. Bowes Hamill, MD, Houston, focused his presentation on iris cysts, highlighting iris stromal cysts caused by implantation of limbal stem cells into the stroma, which can be seen after trauma or after surgery. 
These cysts are frequently large, thin walled, and filled with replicating epithelial cells, Dr. Hamill said, calling this type of cyst “a time bomb.” The location and size of these cysts make it difficult to excise and remove surgically, and there is risk of epithelial ingrowth with cyst rupture. 
When treating the cyst, the goals, Dr. Hamill said, are to remove or debulk the cyst and to prevent the escape of epithelial cells from the cystic space.
He described a modified technique using intralesional ethanol injection for cyst drainage. His method involved entering through the conjunctiva, inserting the needle into the cystic space, aspirating the cyst and collapsing it, and using another syringe to inject alcohol.

Editors’ note: Dr. Raju and Dr. Hamill have no financial interests related to their comments.

EyeWorld reports from the 2018 Combined Ophthalmic Symposium EyeWorld reports from the 2018 Combined Ophthalmic Symposium
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