EyeWorld/ASCRS reporting live from the ASCRS ASOA Annual Meeting in San Diego, Sunday, May 5, 2019


EyeWorld/ASCRS reporting live from the ASCRS ASOA Annual Meeting in San Diego, Sunday, May 5, 2019

The Annual Meeting continued on Sunday with the popular Sunday Summit session, as well as several new symposia.

Team supporting intracameral antibiotics wins The Voice of Ophthalmology

Tal Raviv, MD, New York, with coach Iqbal “Ike” Ahmed, MD, Toronto, Canada, were voted by the audience as the winners of The Voice of Ophthalmology, which took place during the second part of Sunday’s General Session.
Season two of The Voice of Ophthalmology involved contestants sending in video auditions, which were then narrowed down by the Program Committee. Contestants took to the podium at the meeting to share their presentations on several controversial issues. Coaches, with their backs to the contestant, only turned if they wanted to vie for being that person’s mentor, supporting their stance on the issue. Following, a panel of experts presented counterpoints.
Dr. Raviv’s presentation was about endophthalmitis prophylaxis with intracameral antibiotics. Dr. Raviv presented what he called “overwhelming evidence of efficacy” to support the use of intracameral antibiotics. The Kaiser study, he noted, showed a 22-fold reduction of infection over topical antibiotics, and the Aravind study showed a 3.5-fold reduction of endophthalmitis with intracameral moxifloxacin. He also cited several studies that showed no additive effect of topical antibiotics after intracameral antibiotics were used and noted that a 2016 AAO Preferred Practice Pattern supports the role of intracameral antibiotics.
Adoption of intracameral antibiotics among U.S. surgeons, unlike their European counterparts, however, is low. Dr. Raviv said concern could stem from there not being an FDA-approved product and the association of intracameral vancomycin with HORV. Cefuroxime and moxifloxacin are alternatives to intracameral vancomycin for those concerned about the latter. Dr. Raviv said compounding pharmacies and the commercially available topical formulation of moxifloxacin are options for intracameral antibiotics. Dr. Raviv pointed out that ophthalmologists use other drugs in off-label indications quite regularly, as well as compounded formulations of other medications.
Deepinder Dhaliwal, MD, Pittsburgh, gave the rebuttal, saying that because bacteria live in the lids and lashes, preop antisepsis with a double povidone iodine prep should be stressed. This is the key to decreasing the rate of endophthalmitis, she said, and none of the studies mentioned by Dr. Raviv had standardized techniques of preop antisepsis. This, followed by a postop antibiotic regimen, has led to zero cases of endophthalmitis in her practice.
Topical moxifloxacin, Dr. Dhaliwal cautioned, is not 100% effective or benign.
Dr. Ahmed said that antisepsis protocols and intracameral antibiotic use are mutually exclusive. We should do both, he said.

Editors’ note: Drs. Dhaliwal, Ahmed, and Raviv have no financial interests related to their comments.

Become a better doctor and lecturer by making information stick

Any speaker can make his or her message stick in an audience’s mind by adding emotion, prioritizing meaning, and dividing the information into discrete chunks. That was the message John Medina, PhD, gave to attendees at the ASCRS Lecture on Science, Medicine and Technology.
Dr. Medina is a developmental molecular biologist, researcher, and professor at the University of Washington School of Medicine in Seattle. He is also a New York Times bestselling author and considered to be one of the most engaging and crowd-pleasing speakers in the world of neuroscience.
In this inspiring and exciting lecture, Dr. Medina described to attendees several principles of cognitive neuroscience that can help physicians grab and keep the attention of an audience, whether they are lecturing to a room full of people or having a one-on-one chat with a patient. Keeping the audience’s attention will make the information stick and ensure the audience remembers it later, Dr. Medina said.
Dr. Medina explained how human brains pay attention to different stimuli and presented a roadmap of how physicians can apply these principles to everyday communication situations, like giving a lecture to a group of medical students or having a private chat with a patient.
The power of emotion:
Holding a person’s attention is vital for physicians because failing to do it can harm both the doctor and the patient, according to Dr. Medina. To do this, a speaker must evoke an emotional response in the listener.
Dr. Medina cited several recent studies that show when doctors pre-educate their patients about the risks and benefits of an upcoming procedure, the patients tend to recover more quickly, experience less pain, and are less likely to sue the doctor if something goes wrong.
Dr. Medina calls this idea of pre-educating patients “emotional inoculation.” Some physicians may scoff at the idea of explaining to the patient all the possible ways a procedure can go wrong, but because this information triggers an emotional response, the patient is more likely to remember it.
“The more emotionally competent a given stimulus is, the more likely we are to pay attention to it,” Dr. Medina said.
There is an additional reason emotional inoculation works in this type of situation: It gives patients a feeling of control over what is happening to them. 
“It’s not aversive stimuli that cause stress; it’s the ability to feel in control of the aversive stimuli,” Dr. Medina said. “The more out of control the patient felt over the aversive stimuli coming at them, the more likely they were to not remember anything the doctor said and as a direct result, start the litigation process.”
Start with the gist:
When educating others, it’s best to start with the gist rather than the details, according to Dr. Medina. The human brain processes meaning before it processes detail, so presenting the meaning of information first will help it stick in the minds of listeners, he said. One study found that presenting information with the gist first increased recall by 47% compared to presenting the information in a random order.
Dr. Medina gave the example of a prehistoric human running into a saber-toothed cat. The first thing the person’s brain would care about is whether that cat is a physical threat—not the details of the cat’s appearance, like how many teeth it has.
“[The brain] does not want to know the number of vertical lines in a saber-toothed cat’s mouth before it wants to know if that mouth is going to clamp down on your thigh,” Dr. Medina said. “It wants the meaning of the mouth before it wants the detail of the mouth.”
Use chunks:
In addition to prioritizing emotion and meaning, the human brain likes to break large amounts of information down into discrete chunks. Dr. Medina likens this tendency to eating a meal: People consume food by breaking it down into bites, forkfuls, and spoonfuls; they don’t devour it all at once. 
What this means is that when giving a lecture, physicians should divide the talk into short chunks to keep the attendees’ attention. The ideal length of time for each chunk is about 10 minutes because studies have shown a person’s attention tends to fade after the 10-minute mark. 
“You should never again give a 40-minute lecture; instead, you should give four 10-minute lectures and do something at the joints,” Dr. Medina said.
At the “joints,” or end of every 10-minute chunk, the speaker should pull the lens back and look at the bigger picture.
“Every 10 minutes, you have to get off of your granularity, and pull the lens way back and give some meaning,” Dr. Medina said. “If you can make it emotionally competent, even better.”

Editors’ note: Dr. Medina has no financial interests related to his comments.

Pearls for cataracts and ocular surface procedures

Speakers at yesterday’s “Mastering it All” session offered attendees useful pearls for dealing with soft and brunescent cataracts and described new approaches to treating recurrent symblephara and removing the corneal epithelium prior to crosslinking.
Marjan Farid, MD, Irvine, California, shared with attendees a new ocular surface reconstruction technique for treating recurrent symblephara using keratolimbal allograft tissue. This tissue is traditionally used for limbal stem cell transplantation, but it’s a robust tissue alternative to amniotic membrane or conjunctival autografts for recurrent disease, she said.
The tissue preparation for a keratolimbal allograft is similar to that for a limbal stem cell transplant, where the central corneal button is discarded from the donor tissue and the corneoscleral rim is then sectioned. The posterior lamella is excised with crescent blades and the corneal edge is tapered with Vannas scissors. Finally, the tissue segments are custom tailored to the extent of the remaining defect. Multiple segments can be used to cover the entire affected area.
Diplopia in the primary gaze was resolved for all patients who have received this type of graft and had no symblepharon recurrences onto the keratolimbal allograft tissue itself, Dr. Farid said.
Kathryn Hatch, MD, Waltham, Massachusetts, described a new tool for removing the corneal epithelium prior to crosslinking that reduces pain and expedites healing.
The complications of corneal crosslinking are mostly associated with the epithelium removal, and can involve poor healing, infection, pain, vision loss, and haze. The epithelium is traditionally removed with ethanol or an Amoils brush, but these can damage Bowman’s membrane, a considerable risk for keratoconus patients, Dr. Hatch said.
An alternative is the EBK procedure using the Epi-Clear device (Orca Surgical). The Epi-Clear device is made of a biocompatible polymer that collects the epithelium layers into grooves on the device. The procedure causes no trauma and doesn’t damage Bowman’s membrane.
A study comparing the EBK procedure to PRK found EBK patients healed faster, had less pain, and better postop visual acuity.

Editors’ note: Drs. Farid and Hatch have no relevant financial interests.

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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