EyeWorld/ASCRS reporting live from AAO 2019 in San Francisco, Monday, October 14, 2019

 

EyeWorld/ASCRS reporting live from AAO 2019 in San Francisco, Monday, October 14, 2019
It was “Cataract Monday” at AAO, with many sessions focused on this subspecialty, including one on complicated phaco cases and an ASCRS-sponsored symposium. Other topics were covered as well.
Top pearls in complicated phaco cases
Preeya Gupta, MD, Durham, North Carolina, began the session, discussing phaco and ocular surface disease (OSD) and sharing these pearls:

  1. Make the diagnosis of OSD before surgery: Dry eye disease has a potential negative impact on cataract and refractive patients and can lead to poor visual quality, refractive surprise, and discomfort postoperatively.
  2. Use point-of-care testing to help make an OSD diagnosis: The TFOS DEWS II updated definition includes hyperosmolarity and surface inflammation. There are tests to identify both.
  3. Use an algorithm: The ASCRS Preoperative OSD Algorithm is a tool Dr. Gupta mentioned. It highlights the LLPP exam (look, lift, pull, push).
  4. Treat any lumps and bumps on the surface prior to surgery: EBMD and Salzmann’s nodules are very common.
  5. Treating OSD doesn’t have to be hard: There are many medications and procedures to address it.

Another presentation by Douglas Koch, MD, Houston, highlighted phaco after LASIK. Dr. Koch stressed the importance of getting a lot of data and under promising. Additional pearls were “don’t panic and don’t celebrate on Day 1 postop.” He also said the role of intraoperative aberrometry is disputed.
Toric IOLs, Dr. Koch continued, may be a reasonable choice if three criteria are met: regular bow-tie astigmatism within the central 3-mm zone, the difference in corneal astigmatism magnitude between IOLMaster (Carl Zeiss Meditec) and Lenstar (Haag-Streit) is less than or equal to 0.75 D, and the difference in the astigmatism meridian between the IOLMaster and Lenstar is less than or equal to 15 degrees.
His final point was on whether these might benefit from an EDOF or multifocal IOLs. He said “most of us have removed a multifocal or EDOF in a post-LASIK eye.” Dr. Koch’s approach is to consider an EDOF or multifocal if the topography is regular in the central 3-mm zone. He also said there may be a role for the IC-8 (AcuFocus).
Nick Mamalis, MD, Salt Lake City, focused his pearls on dealing with TASS, first highlighting diagnosis. TASS is characterized by acute, postoperative anterior segment inflammation, he said. It’s usually sterile, not infectious, and there is usually immediate onset (within 12–48 hours postop). Dr. Mamalis said to look for diffuse corneal edema, marked anterior segment inflammation, and possible iris damage.
He also explored TASS etiology. First, look at cleaning and sterilization of the ophthalmic instruments—the most commonly associated factor with TASS—he said. He stressed that inadequate flushing of phaco and I/A handpieces is often the culprit. Enzymatic detergents residues have been found to cause TASS in animal studies, Dr. Mamalis said. He also mentioned looking at ultrasound baths and ensuring proper care of these, because endotoxin contamination can occur if they are not properly cleaned.
Dr. Mamalis also highlighted the etiology of TASS relating to ophthalmic products and medications and discussed analysis of TASS. It’s important to rule out infectious etiology, perform careful anterior segment exam with a slit lamp and eventually a gonioscopy, and take IOP measurements. He said to sample and analyze all medications and fluids used during surgery.
Dr. Mamalis’ final pearl addressed the treatment of TASS. He noted that intense topical corticosteroids and NSAIDS can be used.
Inflammation associated with TASS will generally clear rapidly in mild cases, he said. More severe cases can take 3–6 weeks, and patients with very severe cases could have permanent damage.
For white cataracts, Elizabeth Yeu, MD, Norfolk, Virginia, offered the following pearls:

  1. Understand your opponent.
  2. Decompress the nucleus before capsulorhexis.
  3. Opening the anterior capsule may be the most difficult step.
  4. Nuclear densities of white cataracts differ from eye to eye.
  5. Vigilantly protect the posterior capsule.

Editors’ note: Drs. Gupta, Yeu, and Koch have relevant financial interests with a variety of ophthalmic companies. Dr. Mamalis has no relevant financial interests.

Artificial iris implantation
Kevin Miller, MD, Los Angeles, gave the Charles D. Kelman Lecture on the topic of artificial iris implantation during the morning’s cataract session.
Some iris defects can be repaired with sutures, he said, but large defects might need artificial iris devices. Four companies manufacture artificial irises around the world, Dr. Miller said: HumanOptics, Morcher, Ophtec, and Reper.
As a caution, Dr. Miller said, “please do not implant cosmetic anterior chamber artificial irises,” as these cause many problems.
Dr. Miller went into detail on the artificial iris devices from the different companies, specifically the HumanOptics product, which is approved in the U.S.
The template is a photograph of the normal fellow eye (if there is one), he said. It has a 12.8-mm outer diameter and a fixed 3.35-mm pupil. It comes in two models (either fiber containing or fiber free), and it does not contain an integrated optic.
While these devices can reduce light and glare sensitivity, what they do for a person’s psychology, emotional state, and ability to interact with others is really amazing, Dr. Miller said.
Dr. Miller also noted that you can use a passive or sutured fixation method for these devices, and iris insertion can be done with an injector or forceps.
He shared general observations from his experience working with artificial irises. The color match is not always perfect, he said, and the iris does not always center in the eye, especially if it is suture fixated. The pupils of the two eyes will not match under all lighting conditions, he said. Additionally, many of these eyes will require subsequent strabismus surgery. Dr. Miller said that some may also require penetrating or endothelial keratoplasty, and most will require blepharoptosis repair. Glaucoma will continue to be a problem for eyes that had it preoperatively, he said. But, on a positive note, Dr. Miller said the view of the retina and optic nerve is excellent through the artificial pupil.

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

Hot topics in ophthalmology
A Monday morning symposium covered a range of hot topics in ophthalmology.
Mina Massaro-Giordano, MD, Philadelphia, led the session with discussion on treatment for neurotrophic keratitis (NK), which she described as a rare, progressive disease that affects fewer than 65,000 people in the U.S. Nerve malfunction—pain without stain—is a “hallmark” of NK, she said. Oxervate (cenergermin ophthalmic solution, Dompe) is the first FDA-approved treatment for all three stages of NK and the first approved ocular biologic.
Clinical trials showed complete corneal healing in up to 72% of patients at week 8 on Oxervate, Dr. Massaro-Giordano showed, and of these patients, 80% were still healed at 48 weeks after treatment. Mean density of nerve fibers was significantly higher at week 4 and week 8 compared to baseline.
In her clinical experience, Dr. Massaro-Giordano said she has treated patients with Oxervate alone and in combination with other therapies, with most improving to varying degrees (one has worsened). Oxervate is expensive, Dr. Massaro-Giordano acknowledged, with an 8-week course costing $80,000, but she said there are assistance programs to help with copay.
Davinder Grover, MD, Dallas, covered two microshunts in glaucoma surgery: XEN Gel Stent (Allergan) and PreserFlo (Santen, formerly InnFocus MicroShunt). XEN is FDA approved while PreserFlo is in clinical trial vs. trabeculectomy, approved in Canada and Europe. Dr. Grover said these devices are options for patients who don’t have an intact collector system. Like XEN, PreserFlo is also aiming to treat various stages of glaucoma and hopes to be approved as a standalone procedure.
Dr. Grover said he uses XEN on patients who have failed angle surgery or who cannot have angle surgery; those who cannot follow-up easily; advanced disease patients; patients who cannot be off blood thinners for a few weeks; and those with predictable refractive outcomes. He won’t use XEN on patients who have active inflammation; those who have extensive peripheral anterior synechiae superiorly; patients with neovascular glaucoma or angle closure, unless combined with phaco; patients with an AC-IOL or sutured/unstable lens; a patient who might need PKP or who has ICE; and those with a prominent cheek bone/sunken eye.
Dr. Grover said if PreserFlo gets approved, he imagines he will use it on patients who have had failed angle surgery, XEN, and/or incisional glaucoma surgery and who also have a small area of mobile conjunctiva. He also said he might use it in patients with refractory glaucoma and those who are otherwise trabeculectomy candidates. With both of these devices, surgery is “not as easy as it looks,” Dr. Grover said, but with proper training and experience, he added, they provide safe, effective treatments.
Francis Mah, MD, La Jolla, California, discussed new drug delivery methods, focusing on Dextenza (Ocular Therapeutix), an intracanalicular dexamethasone insert indicated for ocular inflammation and pain following ophthalmic surgery, and Dexycu (EyePoint Pharmaceuticals), a dexamethasone suspension delivered intraocularly for postop inflammation at the end of cataract surgery. Both are FDA approved. Overall, Dr. Mah said industry introducing novel drug delivery options improves patient compliance and could ultimately improve patient care.
Other presentations involved rho kinase inhibitors, pediatric myopia control, thyroid eye disease, presbyopia-correcting eye drops, anti-VEGF agents for diabetic retinopathy without macular edema, and optic neuritis.

Editors’ note: Drs. Massaro-Giordano, Grover, and Mah have financial interests with a variety of ophthalmic companies.

‘ASCRS Essentials’ focuses on astigmatism
An ‘ASCRS Essentials’ symposium Monday afternoon zeroed in on astigmatism management at the time of cataract surgery.
It started with a presentation by Yuri McKee, MD, Mesa, Arizona, on IOL calculations. His “biggest piece of advice is to use an IOL calculation from this century.” Dr. McKee recommended the Hill-RBF and Barrett Universal II—which he said have the best refractive results for nearly all eyes—the Barrett True K for post-refractive eyes, and Barrett Toric (used with integrated K). Dr. McKee also said to use EKR65 for mean keratometry value in all eyes with keratoconus, PKP, corneal scarring, or other irregular astigmatism.
Three presentations in the symposium specifically focused on astigmatic correction with toric IOLs, peripheral corneal relaxing incisions, and femtosecond laser arcuate incisions. Nicole Fram, MD, Los Angeles, offered pearls on toric IOLs. This included the importance of meticulous measurement (taking multiple measurements) and marking, use of intraoperative aberrometry or digital marking (when available), removing all OVD from behind the lens, pushing the optic posteriorly, and conducting a balanced salt solution stress test at the end of surgery. Dr. Fram said she will use torics when there is more than 1.25 D of with-the-rule astigmatism and more than 0.75 D of against-the-rule.
Jonathan Rubenstein, MD, Chicago, discussed manual peripheral corneal relaxing incisions (PCRIs), which he said are low-tech, cheap, always accessible, and can be adjunct to toric IOLs. Efficacy of this procedure depends on the technique you use, he said. You need to know a good nomogram and adjust that nomogram based on your results, Dr. Rubenstein said. Measure the thinnest peripheral corneal thickness and set the diamond knife or use a preset 600 µm diamond knife, and make incisions before cataract surgery. He also said it’s important for your blade to maintain perpendicularity with the dome of the cornea to get the full depth. You also need to complete the length of the incision at a consistent, even depth, he added. Dr. Rubenstein said with good technique, and depending on age of the patient, you can correct 1–3 D of astigmatism with PCRIs.
Eric Donnenfeld, MD, Rockville Centre, New York, presented on femtosecond arcuate incisions, which he said are good for 1 D or less of cylinder. Use of the femtosecond laser is more predictable, precise, and less risky than manual, Dr. Donnenfeld said. He then discussed some of his technique, noting that he doesn’t want his incisions to open up too easily. “What I want to create is a femtosecond arcuate incision that opens with a little difficulty,” he said, explaining that he will open one on the table and wait a week before opening the other.
In addition to femto LRIs, Dr. Donnenfeld discussed intrastromal incisions, which he said are good for low amounts of astigmatism and result in less pain and dry eye with no risk of infection.

Editors’ note: Dr. McKee has relevant financial interests with Carl Zeiss Meditec. Dr. Rubenstein does not have financial interests related to his comments. Drs. Fram and Donnenfeld have financial interests with a number 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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