EyeWorld/ASCRS reporting live from the ASCRS ASOA Annual Meeting in San Diego, Monday, May 6, 2019


EyeWorld/ASCRS reporting live from the ASCRS ASOA Annual Meeting in San Diego, Monday, May 6, 2019

The Annual Meeting continued on Monday with a variety of programming, including the Charles D. Kelman Innovator’s Lecture.

Kelman Innovator's Lecture emphasizes importance of collaboration

Ron Kurtz, MD, Aliso Viejo, California, delivered the 2019 Charles D. Kelman Innovator’s Lecture, taking attendees through the process of collaborative innovation. Ann Kelman, wife of the late Dr. Kelman, introduced Dr. Kurtz as a “true entrepreneur and collaborator extraordinaire.”
Invention, Dr. Kurtz said, is a new product or novel process, but innovation is the application of that invention to address a need and create value.
“We start innovation with an invention,” Dr. Kurtz said, but that invention undergoes further development with extensive input from various teams and people. There is the internal innovation team and partners in innovation who aid in development. Then there’s the marketplace for innovation that improves upon and brings an invention through the cumulative adoption process (early adoption, early majority, late majority, and late adopters). 
Collaborative innovation can also happen between technologies where a particular technology can reach a certain level of adoption, but then additional technologies further it. This was seen, Dr. Kurtz said, with phacoemulsification and the development of viscoelastics and folding IOLs to accompany it, for example.
When Dr. Kurtz entered clinical ophthalmology in the 1990s, he said the same process was going on with refractive corneal surgery. Pico (and femto) second laser intrastromal ablation were found to produce a precise sub-surface effect when focused, while the excimer laser provides a precise surface ablation. Gerard Mourou, PhD, developed the first high-power femtosecond lasers with chirped pulse amplification, which Dr. Kurtz explained were intense light pulses that didn’t damage the internal workings of the laser. Dr. Mourou later founded a research center at the University of Michigan where Dr. Kurtz was a resident. There, Dr. Kurtz encountered a graduate student who had an accidental laser eye injury. This got him interested in the technology—after he emphasized laser eye safety to the team.
Dr. Kurtz started collaborating with Tibor Juhasz, PhD. Eventually, they decided to commercialize the technology. It held both technical and clinical challenges that had to be overcome, including size, patient interface, cost, laser parameter setting optimization, flap lifting techniques, patient flow, and more.
“Together we made advances that were necessary to introduce this technology into the marketplace in 2002,” Dr. Kurtz said.
Since then, it has undergone a number of marketplace innovations including increased laser repetition rate to improve resection quality and day 1 vision and improved reliability to maintain surgeon confidence.
“Over the course of a number of years, a number of companies joined in this technology, and currently, according to MarketScope, about 70% of U.S. LASIK procedures are performed with a femtosecond laser,” he said.
Dr. Kurtz then described moving femtosecond laser technology into the realm of refractive cataract surgery. Refractive cataract surgery, he said, really began in the 1960s, driven by the large pool of patients who, thanks to Medicare, would not have access to these innovations. Innovations included the first implantable IOLs, followed by phaco, viscoelastic, keratometry, biometry, and IOL power calculation formulas. There was a resurgence in refractive cataract surgery innovation—presbyopia correcting and toric IOLs, diagnostics, and surgical techniques—spurred on by the 2005–06 CMS Dual Aspect Rule, Dr. Kurtz said. Femtosecond laser-assisted cataract surgery was introduced to the market in 2012, and in the time since, Dr. Kurtz said it has undergone this same process of marketplace-drive innovation with improvement in capsulotomy quality, fragmentation patterns, and integration of surgical planning and diagnostic tools.
Four years ago, Dr. Kurtz said he took a hiatus from the femtosecond laser and focused his efforts on the Light Adjustable Lens (RxSight).
“I was intrigued by the ability to have an office-based system that could optimize patient vision after the cataract had been removed,” he said.
Dr. Kurtz said this innovation, which is already FDA approved, uses a specific pattern of UV light to change the shape of the implanted IOL according to the prescription for the patient. The Light Adjustable Lens, Dr. Kurtz continued, is meant to overcome the limitations of the preop and intraoperative prediction process. It is beginning a new journey in 2019, entering the era of marketplace innovation for this technology, he said.

Editors’ note: Dr. Kurtz has financial interests related to his comments.

Keeping an eye on innovation

Monday’s Innovators General Session gave attendees a look at several advances coming down that pike, as well as a little bit of history. 
Patrick Riedel, MD, Minneapolis, described a new place to shunt aqueous: the ocular surface. The Beacon Aqueous Microshunt (MicroOptix)—the brain child of David Brown, MD, 20 years in development—is 3.1 mm in length with an external flange width of 7 mm. It is implanted into a paracentesis-like incision, allowing aqueous to flow through a central channel.
Mitigation against retrograde flow of pathogens would be a concern for such an idea. However, Dr. Riedel said that this is prevented 1) by shear stress and 2) by the polyethylene glycol material that composes the central layer of the three-layer device. Polyethylene glycol is considered the gold standard of anti-biofouling materials. It is super hydrophilic, and it prevents adherence of protein and bacteria to the channel wall, Dr. Riedel explained.
In a porcine animal model followed to 6 months, Dr. Riedel noted no infections and significant, persistent IOP lowering. An aggressive bacterial challenge with the device on eight animals did not result in endophthalmitis, Dr. Riedel continued.
Preliminary data from an early bird study in the U.S. and E.U. has shown a mean IOP of 13 mm Hg at 6 months, compared to a baseline mean of 27 mm Hg that was medicated with no washout of patients. Eighty-seven percent of patients showed a 20% reduction in pressure compared to baseline, and all patients except one were off all medications postop. Most patients, Dr. Riedel said, were very or extremely comfortable at 6 months.
In terms of safety, there were no infections or uveitis, no dislocations or device migration, and no sight-threatening complications. There were three device blockages, two of which resolved completely with no or minimal intervention. The third was removed for persistent blockage.
Dr. Riedel said investigators will soon conduct a prospective, multicenter study to evaluate safety and efficacy in refractory glaucoma.

Editors’ note: Dr. Riedel has financial interests related to his comments.

TOPGUN symposium provides essential cataract pearls

Experts from four international cataract and refractive surgery societies gathered at the TOPGUN symposium Monday afternoon to give their most essential pearls for cataract surgery.
David Chang, MD, moderator, Los Altos, California, said there is nothing exotic in this session, rather practical pearls that you can take back and apply in your practice. Experts in four categories gave their essential pearls and the audience voted on who they thought was the best instructor. Following all the presentations, the audience voted on the best team.
Team Pan Am-Blyopes, which included experts from ASCRS and the Latin American Society of Cataract and Refractive Surgeons was voted the best team. Experts from the Asia-Pacific Association of Cataract and Refractive Surgeons and the European Society of Cataract and Refractive Surgeons represented the Crazy Rich Eur-Asians team.
Following are brief highlights from the instructors who won in each category.
Phaco pearls: Arnaldo Espaillat, MD, Santo Domingo, Dominican Republic
Dr. Espaillat presented several pearls in his presentation “Phaco diversity.” To avoid the Argentinian flag sign in intumescent white cataracts, stain with trypan blue, insert a cohesive OVD, and pinch through the corneal limbus with a needle, aspirating milky fluid the same time you penetrate the capsule, he said. Another tip he provided was to chop the nucleus into eight pieces, using torsional ultrasound in pulse mode. Dr. Espaillat injects dispersive OVD frequently to protect the corneal endothelium. If you see white, milky material near the phaco tip, Dr. Espaillat said it is likely occlusion with viscoelastic and nuclear material; stop doing phaco. This pause will help avoid corneal burns. In post-RK eyes with eight incisions, Dr. Espaillat said to do a 2.2-mm scleral tunnel and a 1-mm side port through the corneal limbus between radial cuts. 
IOL pearls: Ronald Yeoh, MD, Singapore
Dr. Yeoh gave several pearls for injecting single-piece IOLs. First, he highlighted several things that can go wrong, such as the plunger going under the IOL, a trailing haptic stuck in the cartridge, and lens stuck in the incision (Winnie the Pooh syndrome). Dr. Yeoh then provided his four essential tips for implantation.
1) Load the IOL true with adequate OVD in the cartridge. Loading the IOL true, he explained, means following the picture of the IOL on the cartridge.
2) Depress the optic to create concavity to receive the haptics.
3) Watch the IOL as it travels down the injector cartridge.
4) Maintain adequate forward pressure in wound-assisted implantation.
Complex case pearls: Kendall Donaldson, MD, Plantation, Florida
Dr. Donaldson gave her tips for pars plana vitrectomy. Plan in advance for these cases, when possible. Recognize when there might be a broken posterior capsule with an intact hyaloid versus when there might be vitreous prolapse. Viscoelastic should be used to avoid shallowing on the anterior chamber and further vitreous prolapse. Stain with triamcinolone to visualize vitreous. Vitrector settings should be set at the highest cut rate with irrigation/cut/aspirate for vitreous. The vitrector should be inserted 3.5 mm posterior to the limbus with or without a trocar. Always visualize the port and do not vitrectomize through the primary incision. IOL options include a three-piece IOL in the sulcus or consider optic capture. Suture the wound closed and use acetylcholine chloride. Never sweep vitreous and be sure to monitor postop.
Miscellaneous pearls: Sri Ganesh, MD, Bangalore, India
Dr. Ganesh described a novel technique for posterior capsule rupture rescue. When no vitreous is coming forward through the rent and when you are on I/A, Dr. Ganesh proposes remaining in the eye with your instruments and using the I/A handpiece to create what he called the “vacuum rhexis.” This should only be done when the PCR is less than 3 mm; when it is created during I/A; when there is no vitreous loss; and using coaxial I/A, Dr. Ganesh stressed. By keeping instruments in the eye, it prevents shallowing of the anterior chamber and subsequent vitreous prolapse. In a series of 12 eyes, this technique has shown no extension of the tear, no vitreous loss, and 100% planned IOL placement in the bag.

Editors’ note: The speakers have no financial interests related to their comments.

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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