EyeWorld/ASCRS reporting live from the ASCRS ASOA Annual Meeting in San Diego, Saturday, May 4, 2019


EyeWorld/ASCRS reporting live from the ASCRS ASOA Annual Meeting in San Diego, Saturday, May 4, 2019

The Annual Meeting officially kicked off on Saturday, with opening sessions, symposia, and a variety of other sessions.

OGS highlights ASCRS mission, honors Distinguished Member Hal Kushner, MD

The Annual Meeting officially kicked off on Saturday morning with the ASCRS Opening General Session (OGS). Among the highlights of the session was a special presentation to Hal Kushner, MD, this year’s recipient of the first ASCRS Distinguished Member Award.
Thomas Samuelson, MD, Minneapolis, outgoing ASCRS president, shared a special video compilation honoring Dr. Kushner, who received the inaugural ASCRS Distinguished Member Award. Dr. Kushner was a prisoner of war for 5 years and the only physician among 591 American prisoners during the Vietnam War. He survived after his helicopter crashed into a mountain in South Vietnam. After losing his entire crew, Dr. Kushner was captured by the Viet Cong and endured horrific conditions as a prisoner of war. Dr. Kushner was finally released when the war ended and was able to come home to his family, including his son who was born 4 months after he was captured.
During the session, Dr. Kushner detailed some of what he endured, including walking some 560 miles in 57 days to a jail in Hanoi.
“Every minute I was captured, I thought about being a physician,” Dr. Kushner said, adding that he had plenty of time to think about what specialty of medicine to go into and choosing ophthalmology was the best decision he ever made. Dr. Kushner has been a member of ASCRS for 40 years (after first joining the American Intraocular Implant Society in the late 1970s).
He concluded by saying that he has no bitterness, only that he feels lucky and blessed and is proud to have served his country. “I owe my fellow soldiers my life,” he said.

Binkhorst Lecture highlights ‘the quest for tear stability’

This year’s Binkhorst Lecture was delivered by Stephen Pflugfelder, MD, Houston, during the ASCRS Opening General Session. The Binkhorst Lecture award has been given annually since 1975, said ASCRS Program Chair Edward Holland, MD, Cincinnati. “It’s ASCRS’ highest award.”
Dr. Pflugfelder spoke about “The Quest for Tear Stability.” Tear stability is maintained by the lacrimal functional unit. Tear instability is a common feature of all types of tear dysfunction and a defining feature of dry eye, he said. It causes inflammation, increases blinking, degrades visual function, and stimulates corneal nociceptors. He said that there are increasing therapeutic options with different mechanisms of action to improve tear stability.
Dr. Pflugfelder described the inspiration behind the choice of this topic for his lecture. After being asked to give the Binkhorst Lecture, he went to the topography area in his clinic and noticed bottles of artificial tears. “I realized what our technicians figured out a long time ago—that a stable tear film is a big deal,” he said.
A stable tear film protects and smooths the corneal surface, maintains comfort and quality vision during interblink intervals, and is a key determinant of a successful outcome in vision correction surgeries.
“Tear instability is a sine qua non for tear dysfunction,” he
said. Tear instability is also a criterion in recent consensus dry eye definitions.
Fluorescein tear breakup
time remains the most common clinical test and gold standard for detection of tear instability. There is increased interest in non-invasive breakup methods, Dr. Pflugfelder said, because they provide
a digital record, and fluorescein can affect tear stability. Most non-invasive methods provide kinetic analysis of smoothness/spacing of reflected Placido rings. Non-invasive methods may also identify/locate destabilizing cornea/ocular surface pathology, he noted.
Tear instability can be caused by a variety of factors, Dr. Pflugfelder said, including neuropathy, systemic medications, cosmetic surgery, diet, environment, LASIK, eye drops, and aging.
Conjunctival chalasis is a common cause, particularly in age-related tear instability.
Tear dysfunction is also recognized as a major cause for multifocal IOL dissatisfaction.
Tear instability has a number of consequences for the ocular surface including inflammation, increased blink rate, decreased functional vision, and irritation/pain. It is also recognized to impact vision.
On the “road to tear stability,” Dr. Pflugfelder said to identify the root causes, modify the environment (increase humidity and minimize air drafts), correct lid and conjunctival abnormalities, and direct therapy to deficient tear components. When conventional therapies fail, consider scleral lenses to protect vulnerable corneas.
In summary, Dr. Pflugfelder said that tear instability is a shared feature of all tear disorders. Many factors contribute, and tear instability causes altered tear composition, visual fluctuation, inflammation, increased nociception, and increased blinking. It may also cause dissatisfaction with vision correcting surgeries. Dr. Pflugfelder suggested targeting therapies to the underlying causes of tear dysfunction.

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

Learning from challenging and complicated cases

The Young Eye Surgeons (YES) Clinical Committee sponsored a symposium on Saturday that included rapid-fire complicated case presentations and panel discussion, providing attendees with several pearls and lessons learned.
Claudia Perez-Straziota, MD, Los Angeles, led the session with the case of a tumultuous toric patient. The patient was 1 month postop and 20/200 in the right eye. Dr. Perez-Straziota found the IOL rotated 30 degrees from its intended axis and noted the presence of an anterior capsule tear. 
“What would you do when you have a tear intraoperatively and you were planning to implant a toric lens?” Dr. Perez-Straziota asked the panel.
The question is how much astigmatism there is, said Zaina Al-Mohtaseb, MD, Houston. If it’s a lot of astigmatism, this would eliminate options like an LRI or laser vision correction. If the anterior capsule tear is small and the orientation is reasonable for the lens, a toric can be used, she said.
“It’s all about stability of the lens,” Dr. Al-Mohtaseb explained.
What about handling this patient with the tear and subsequent rotation postop? Dr. Perez-Straziota said due to significant anisometropia, she would discourage spectacles. Laser vision correction was discussed, but the amount of astigmatism would make this option challenging. The patient also did not want to wear rigid gas permeable lenses to minimize anisometropia. As such, Dr. Perez-Straziota discussed rotating the lens with the patient, but noted that the existing tear made for a more delicate procedure that might require conversion to a different approach.
Zachary Zavodni, MD, Salt Lake City, gave some basics for capsular tension ring placement. CTRs redistribute forces in the bag, preventing asymmetric phimosis of the bag, recenter the bag, and allow you to put something in the bag that you might not have otherwise been able to do, Dr. Zavodni said. These devices are used in cases of loose zonules and mild zonular weakness or dialysis.
Ideally, CTRs are placed after phaco and cortex removal, Dr. Zavodni said. It is important to fill the capsular bag to provide space for CTR placement and keep iris hooks in place. The goal is for a soft, broad-based landing of the CTR, Dr. Zavodni said. This can be done with an inserter or manually, depending on surgeon preference. Dr. Zavodni said he prefers using a 10.0 nylon suture or a Sinskey hook to aid in insertion. Dr. Al-Mohtaseb said she prefers to insert manually, using a Sinskey, though not through the eyelet but around the CTR as she threads it into the anterior chamber. Naveen Rao, MD, Burlington, Massachusetts, said you could also use micrograsping forceps to guide insertion.
Sumitra Khandelwal, MD, Houston, pointed out the importance of getting the CTR into the capsule, not leaving a portion in the sulcus. A sign that an edge is in the sulcus is if the capsulorhexis is no longer round.
Julie Schallhorn, MD, San Francisco, and David Crandall, MD, Detroit, both spoke about anterior vitrectomy, with Dr. Schallhorn providing pearls and Dr. Crandall showing what not to do. When you notice a break and vitreous coming forward, take out your second instrument but leave irrigation in to maintain the anterior capsule, Dr. Schallhorn advised. Put in viscoelastic at the break first, she continued, then fill.
At that point, Dr. Schallhorn said to make a second paracentesis (one that’s not too long), introduce the vitrector, and put irrigation in to keep the eye inflated. Clean up vitreous that’s coming up into the anterior chamber in a slow and steady manner, Dr. Schallhorn said. Following, you can address the residual lens material and cortex with phaco or with the vitrector.
Other pearls Dr. Schallhorn offered were to use triamcinolone to stain for remaining vitreous and pay attention to the anterior capsule to avoid eating it up with your vitrector. Michael Patterson, DO, Crossville, Tennessee, said he will always do a pars plana vitrectomy.
“I think your best bet is to clear the vitreous posteriorly, that way it won’t come anteriorly,” Dr. Patterson said.

Editors’ note: Drs. Al-Mohtaseb, Schallhorn, and Crandall have financial interests with a number of ophthalmic companies. Drs. Perez-Straziota, Zavodni, Rao, Khandelwal, and Patterson do not have financial interests related to their comments.

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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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