EyeWorld/ASCRS reporting live from the ASCRS ASOA Annual Meeting in San Diego, Friday, May, 3, 2019


EyeWorld/ASCRS reporting live from the ASCRS ASOA Annual Meeting in San Diego, Friday, May 3, 2019

Subspecialty Day programming took place on Friday, with sessions focusing on refractive, cornea, and glaucoma topics.

Steinert Refractive Lecture seeks to correct LASIK myths and misconceptions

The 2019 Steinert Refractive Lecture at the 2019 ASCRS Refractive Day was presented by Eric Donnenfeld, MD, Rockville Centre, New York.
Dr. Donnenfeld said delivering the Steinert Refractive Lecture was one of the great events of his life. His lecture focused on the “Myths, Misconceptions, and Reality” of LASIK.
· Myth #1: Physicians would not have LASIK on their own eyes. Literature presented by Dr. Donnenfeld shows that physicians have the highest prevalence of having LASIK compared to other occupations. Refractive surgeons, in particular, one study showed, were four times more likely to have laser vision correction than the general population. 
· Myth #2: The long-term effects of LASIK are not known. In actuality, there is more than 20 years of data for LASIK, Dr. Donnenfeld said. Long-term studies have shown both refractive stability and safety of the procedure.
· Myth #3: Contact lenses are safer than LASIK. Published research presented by Dr. Donnenfeld reports that daily contact lens wear for 30 years is less safe than LASIK, and extended wear contact lenses have a lesser safety profile. A study of 1,800 patients comparing LASIK to contact lenses showed better patient satisfaction, better night driving, and less infection in those who had LASIK.
· Myth #4: LASIK increases the risk of glare and halo compared to glasses. While LASIK can induce such visual abnormalities in a minority of patients, Dr. Donnenfeld showed data that found modern LASIK can actually cure such problems.
· Myth #5: The safety and efficacy of LASIK has not improved over time. Quite the contrary, Dr. Donnenfeld said. One paper he highlighted on this front showed a 10-year history of continuous improvement of the procedure. This improvement, Dr. Donnenfeld said, will only continue as technology advances. LASIK, Dr. Donnenfeld said, is the safest procedure with the greatest patient satisfaction of any elective surgery performed worldwide.  
· Myth #6: Dry eye is extremely common after LASIK. Research has shown that dry eye is common after LASIK in the first 3 months postop, but it largely resolves after 6 months.

In 2008, 140 complaints were brought to the FDA about LASIK and a public hearing was held. Dr. Donnenfeld attended and testified on LASIK’s behalf at this hearing but, he said, he mostly listened. Patients with adverse results after LASIK expressed feeling like they were not listened to by their surgeon, like they were abandoned. At that time, Dr. Donnenfeld said he promised himself—and he challenges others—to embrace unhappy patients who come to him (whether he performed the surgery or not), making them feel like they have someone who will pay attention and listen to their problems. Dr. Donnenfeld said his ultimate message is that we need to embrace patients who are dissatisfied following LASIK and never let them feel abandoned.
All surgeries will have some complications, Dr. Donnenfeld said, but the relationship between ophthalmologists and industry have addressed many of them.
“Every time we as a group identified a problem, we sought a solution. Problems we identified have been resolved significantly with better technology,” Dr. Donnenfeld said.
Centration of treatments has been improved with the advent of pupil tracking and centroid shift and cyclotorsion compensation; mitomycin-C has reduced incidence of haze; and there are fewer flap complications with better microkeratomes and use of femtosecond lasers. Glare and halo have been reduced with blended zones, customized ablations, and optimized ablations. Ectasia has been “markedly resolved” with better diagnostic equipment leading to better patient selection. If ectasia does occur, Dr. Donnenfeld said we have a “cure” with corneal collagen crosslinking.
Advanced wavefront ablations, which provide more resolution, are bringing 93.4% of patients to 20/20 UCVA, Dr. Donnenfeld said. Similarly, topographic laser ablations are bringing 92.7% of patients to 20/20 UCVA, in addition to offering the ability to treat irregular corneas. SMILE, Dr. Donnenfeld continued, expands options to customize laser vision correction to the right patient.
“The golden age of laser vision correction is today, and tomorrow looks even brighter,” Dr. Donnenfeld said, before adding that while “we should be proud of what we have accomplished, we should never be satisfied.”

Editors’ note: Dr. Donnenfeld has financial interests with various ophthalmic companies.

GFC debate tackles topic of 24-hour IOP monitoring

Douglas Rhee, MD, Cleveland, remains the undefeated, reigning champ of the Glaucoma Fighting Championship (GFC), defending his title against Iqbal “Ike” Ahmed, MD, Toronto, Canada, on the topic of whether 24-hour IOP monitoring is relevant.
Steve Sarkisian, MD, Oklahoma City, refereed the event, telling the contenders that he wanted a “clean fight.”
“Ike, you only get two short jokes. Doug, you only get two hair jokes,” he quipped.
Dr. Ahmed and Dr. Rhee were a bit tamer in the personal punches they pulled at each other than in years past, but they left everything at the podium when it came to defending their positions.
Dr. Ahmed led his argument with a case. A 52-year-old female with mild to moderate glaucoma was showing signs of progression despite “normal” IOPs in office visits. She was on prostaglandins and was compliant. This patient underwent the water drinking test and used Icare Home (Icare USA) tonometry. These tests showed significantly elevated peak IOP and fluctuations.
“This changed our mind that we need to do something for this patient, and it explained progression when she had normal pressure in the office,” Dr. Ahmed said
He went on to highlight several studies that he said provide strong evidence that peak and fluctuation are very important for progression, though he noted other long-term studies suggest the opposite.
Taking to the podium, Dr. Rhee said that while it’s alluring to believe diurnal IOP is important, it’s really mean IOP that affects progression. Dr. Ahmed, Dr. Rhee accused, mixed and matched terms in his presentation. Diurnal IOP variability is different than intervisit variations, the latter of which can result from patient incompliance, procedures, and other factors. Some of the studies mentioned by Dr. Ahmed, Dr. Rhee said, deal with intervisit variability.
Circadian variations of IOP is normal, Dr. Rhee said, yet only 2 to 5% of people have glaucoma. Just forced blinking, he noted, can cause a pressure of 20 to 60 mm Hg, but that doesn’t seem to cause damage.
Studies have shown that when you have higher pressure you have more IOP variability, but the percentage of variability is similar. High variability is just a marker for higher mean IOP, Dr. Rhee said.
In the literature, Dr. Rhee said there are only four papers that measure true circadian IOP; the others study intervisit variability. If you look at the circadian rhythm IOP studies, do they show a correlation between fluctuation and progression? “Maybe,” Dr. Rhee said, also noting a body of literature against IOP fluctuation being correlated with disease progression.
“It’s really the mean IOPs that ended up being important,” Dr. Rhee said.
He also said that if IOP fluctuations were really influencing progression, wouldn’t trabeculectomy be curative? Trab, he said, virtually eliminates fluctuation, and yet it’s certainly not a cure.
“It’s the level of IOP that’s the problem,” he said. “Too high is too high.”

Editors’ note: Drs. Ahmed and Rhee have financial interests with various ophthalmic companies.

Cornea Day features presentation of the ASCRS Preoperative OSD Algorithm

An afternoon Cornea Day session focused on preparing the ocular surface for cataract surgery. During the session, Chris Starr, MD, New York, shared a review of current OSD/DED algorithms.
We are living in an era of algorithms, he said. There has been a rise in OSD in the last 15 years and with that, a rise in interest in algorithms.
Dr. Starr highlighted the ASCRS Preoperative OSD Algorithm, which was created by the ASCRS Cornea Clinical Committee and was just unveiled.
Dr. Starr noted that ocular surface disease is common but often asymptomatic in cataract patients. He added that it can also be visually significant. Visually significant ocular surface disease (VS-OSD) reduces accuracy of preoperative refractive measurements, reduces visual quality and quantity pre- and postoperatively, and blepharitis may increase the risk of endophthalmitis.
The goal of the ASCRS Cornea Clinical Committee was to create a “true algorithm” that was consensus- and evidence-based, that could be integrated into preoperative surgery visits, had reliance on tech and objective testing to reduce chair time, and that identified all visually significant subtypes of OSD prior to surgery.
Dr. Starr described the long evolution of the ASCRS algorithm, ending with the current iteration that was just released. He described the key steps of this algorithm.
It begins on the preoperative visit, and the first step is noninvasive refractive surgical planning tests (there is a possibility that these tests will need to be repeated later if VS-OSD is detected).
The second step is an OSD screen, looking at symptoms and signs. To look at symptoms, Dr. Starr said a novel questionnaire can be used, and to look for signs, he mentioned using the osmolarity and MMP-9 tests. If any is abnormal, OSD is likely, he said, adding that any subtype of OSD can potentially be visually significant. Osmolarity is used primarily as an assessment for DED, and MMP-9 is a non-specific inflammatory marker.
Step 3 of the algorithm is a direct, quick exam to assess for VS-OSD. Dr. Starr said to use “LLPP”: look, lift, pull, push, then stain.
The next step is that OSD is ruled in or out, and if it’s ruled in, you need to determine visual significance. If there is non-visually significant OSD, surgery can proceed, and the refractive plan can be finalized. However, if there is VS-OSD, the surgery and refractive plan should be delayed, the patient should be counseled on OSD impact on surgery, and you should start aggressive treatment to minimize delay, Dr. Starr said.
Step 5 of the algorithm is to treat VS-OSD based on subtypes and severity. Overall, it’s more aggressive therapy than routine OSD, and Dr. Starr added that you should start at TFOS DEWS II step 2 or 3, then prescription medication, procedural treatments, and follow-up in 2 to 4 weeks. He said to proceed with surgery only when VS-OSD is converted to non-visually significantly OSD.
In conclusion, Dr. Starr said, whether one adopts these algorithms faithfully, partially, or not at all, ASCRS encourages all refractive surgeons to pay close attention to the visually important ocular surface prior to surgery.

Editors’ note: Dr. Starr has financial interests with various 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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