EyeWorld/ASCRS reporting from ASCRS Winter Break in Park City, Utah, Saturday, February 1, 2020


EyeWorld/ASCRS reporting from ASCRS Winter Break in Park City, Utah, Saturday, February 1, 2020
The final day of the Winter Break program featured presentations on a variety of cataract and cornea topics.
Cataract surgery in corneal disease

In the first session of the day, Nicole Fram, MD, Los Angeles, California, discussed cataract surgery in corneal disease.

She began by discussing keratoconus. To make an educated decision, Dr. Fram said you need a thorough history, diagnostics and imaging, and experience and judgement. Preoperative considerations include careful consideration for IOL selection, knowing if the patient is contact lens dependent (and tolerant), knowing if the cornea is stable, knowing the optical status of the fellow eye, and knowing if the astigmatism is reproducible across devices and somewhat regular (if so, you could potentially use a toric IOL).

Dr. Fram shared a case presentation and shared that she uses topography, IOLMaster 700 (Carl Zeiss Meditec), and LENSTAR (Haag-Streit).

She also mentioned the importance of counseling the patient about IOL exchange prior to surgery.

Moving on to discuss RK, Dr. Fram called it “the gift the keeps on giving.” These patients often have hyperopic progression, AM to PM fluctuation, and hyperopic surprises, she said. It may be difficult to obtain the flattest K. She also advocated for caution using aberrometry and toric IOLs in these patients.

Dr. Fram shared some RK intraoperative considerations, recommending a corneal incision for up to 8 RK cuts or a scleral tunnel for 12 and above or for asymmetric cuts. She said to stain the capsule; avoid multifocal IOLs; avoid small diameter IOLs; use aspheric IOLs; use toric IOLs only if cylinder is reproducible; and prevent pressure elevation intraoperatively and postoperatively.

She also mentioned the importance of stability in topography postoperatively.

Dr. Fram concluded saying that these patients having cataract surgery who also have corneal disease must be counseled at length; the surgeon should be prepared to exchange the IOL, she said. Formulas and diagnostics are improving, she added, and there may be a role for corneal crosslinking in these patients or for pinhole technology (particularly for highly aberrated corneas).

Editors’ note: Dr. Fram has financial interests with a variety of ophthalmic companies.

Phaco hacks

During a Saturday session, Robert Cionni, MD, Salt Lake City, Utah, discussed “phaco hacks,” sharing some of the tips and tricks he has learned.

He first discussed hydrodissection, saying that he only hydrodissects one small area, and that’s usually all you need, he said. If one wave doesn’t do it, Dr. Cionni will decompress and then put in more fluid and decompress again. He added that he also really likes pre-chop because everything is already broken up, and you haven’t used any fluid or energy.

Dr. Cionni also highlighted how he generally uses a one-handed technique. Don’t put a second instrument in unless you need it, he said. This way, you will only have one spot of egress of fluid, and you will also have better stability and a more efficient procedure. Dr. Cionni said he generally doesn’t have to move the tip much. If things are coming to it, there’s no need to do manipulation, he said.

Dr. Cionni also suggested that if you have trouble with tremors during surgery, you can use your second hand to put the index finger right at the incision.

Editors’ note: Dr. Cionni has financial interests with Alcon and Morcher.

Corneal lumps and bumps

During her presentation on corneal lumps and bumps, Darcy Wolsey, MD, Salt Lake City, Utah, shared several case presentations.

She first highlighted a patient who was unhappy after a toric IOL. The patient had a small pterygium and huge wedge of Salzmann’s nodules.

Dr. Wolsey described Salzmann’s nodules as white/gray/bluish scar tissue bumps that are usually on the peripheral cornea. This can have vessels and can cause significant irregularity and flattening of the cornea. She also said to watch for mild subepithelial fibrosis (especially under the lid).

Salzmann’s nodules are also more likely to occur in women, and in Dr. Wolsey’s patient, they were hiding under her lid.

To treat, Dr. Wolsey uses superficial keratectomy, adding to gently remove the overlying epithelium. You need to go further away than you think, she said, stressing that you need to find the “edge,” and then the Salzmann’s nodules usually peel up easily.

Following treatment for Salzmann’s nodules, Dr. Wolsey said she uses a bandage contact lens, antibiotic drops, and a steroid taper for around 2 weeks.

On her patient, Dr. Wolsey removed the Salzmann’s nodules and the pterygium. At 1 month, the patient was looking great, but the toric wasn’t working correctly.

Dr. Wolsey said, at this point, you could consider an IOL exchange or a rotation. She didn’t think she could rotate the toric lens, so she did an IOL exchange and optic capture. However, this didn’t solve her problem. Dr. Wolsey said that she thinks she went too fast in this case because she didn’t get repeat measurements. There was astigmatism on the cornea, which impacted the outcome. This is a good example of needing to wait (6–8 weeks) and get repeat measurements, Dr. Wolsey said, noting that rotating the IOL may have been the best option in this case.

Editors’ note: Dr. Wolsey has no relevant financial interests.

Management of the rotated toric IOL

Douglas Koch, MD, Houston, Texas, highlighted how to manage rotated toric IOLs. He noted three causes of residual ametropia: misalignment of the IOL with correct spherical power and toricity, inaccurate IOL toric power, and inaccurate IOL spherical power.

Options to address these issues, Dr. Koch, said can be IOL based (rotation, exchange, or piggyback IOL) or corneal based (relaxing incisions, excimer laser ablation, or SMILE).

Dr. Koch said that it’s also important to know if the IOL spherical power is accurate, if the IOL toric power is accurate, and what the magnitude of the residual astigmatism is.

If the spherical power is off, Dr. Koch said excimer laser can be used, especially if it’s a small correction, and he will use this with up to 1.5 D of myopia or up to 1 D of hyperopia.

For larger residual error, Dr. Koch said an IOL exchange may work better, but he noted that this may not be covered by insurance. The patient may insist on this, he said, if they believe they have the wrong lens in their eye.

Dr. Koch said he likes to use relaxing incisions when patients have a small amount of residual astigmatism. He shared a case of a 77-year-old patient, and he had put a lens in her eye at 163 degrees, and the lens rotated. Instead of going back in to rotate it, Dr. Koch just did paired relaxing incisions, and a month later, she was 20/20.

Editors’ note: Dr. Koch has financial interests with a variety of ophthalmic companies.

Handling neurotrophic keratitis

Dr. Fram also presented on neurotrophic keratitis, offering pearls for dealing with this issue. She first highlighted the pathophysiology, noting the impaired corneal innervation, as well as trophic factors and impaired trigeminal reflexes. The etiologies are complex, she said, adding that there could be ocular conditions, systemic conditions, or central nervous system conditions.

Dr. Fram offered her top five pearls for neurotrophic keratitis:

  1. Determine etiology. Take a thorough history, Dr. Fram said.
  2. Look at the meds. She recommended changing topical medications to preservative free.
  3. Use amniotic membrane early in refractory disease.
  4. Evaluate and treat abnormal eyelid anatomy and disease.
  5. Know when a tarsorrhaphy is necessary and act quickly to avoid corneal thinning.

Editors’ note: Dr. Fram has financial interests with a variety of ophthalmic companies.

EyeWorld Onsite is a digital publication of the American Society of Cataract and Refractive Surgery and the American Society of Ophthalmic Administrators.

Medical editors: Eric Donnenfeld, MD, chief medical editor; Rosa Braga-Mele, MD, cataract editor; Clara Chan, MD, cornea editor; Nathan Radcliffe, MD, glaucoma editor; Vance Thompson, MD, refractive editor

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