­EyeWorld/ASCRS reporting live from the ASCRS ASOA Combined Ophthalmic Symposium in Austin, Texas, Saturday, August 24, 2019


EyeWorld/ASCRS reporting live from the ASCRS ASOA Combined Ophthalmic Symposium in Austin, Texas, Saturday, August 24, 2019
COS programming was in full swing on Saturday in Austin, with presentations in the ophthalmology, young eye surgeons (YES), ASOA, and optometry programs.
'The Practical Guide to Cataract Essentials'
Kicking off the ophthalmology program on Saturday, Mitchell Weikert, MD, Houston, shared some tips for using miLOOP (Carl Zeiss Meditec) for dense cataracts, which he said has been a "game changer in relieving a lot of the stress of these surgeries."
These cases typically require a lot of ultrasound power, but Dr. Weikert said using miLOOP drastically cuts down on phaco energy he uses on dense lenses. Dr. Weikert recommended starting with regular cataract cases before using miLOOP for dense cases.

Dr. Weikert’s key takeaways included:

  • Stain the capsule and size the capsulorhexis appropriately
  • Understand the mechanics of snare expansion/contraction
  • Carefully pass the snare under the stained capsule
  • Monitor instrument angle
  • Maintain black ring at incision
  • Use a second instrument to prevent lens tilt
  • Anticipate delay of the snare with rotation and go beyond the midline
  • Carefully break the nuclear bridge
  • Rotate with a second instrument and fracture a second time

Editor's note: Dr. Weikert has financial interests with Alcon and Ziemer.
Best of ASCRS
During another Saturday morning session, presenters shared a number of paper presentations that they found interesting from the 2019 ASCRS Annual Meeting.
Nick Mamalis, MD, Salt Lake City, and Jonathan Solomon, MD, Bowie, Maryland, highlighted some of their choices for cataract and anterior segment topics.
One paper Dr. Mamalis shared was “Are Perioperative NSAIDs Really Necessary in Preventing Cystoid Macular Edema if IOP is Adjusted Immediately after MICS or FLACS.” The study found that immediate postoperative IOP that was thought to be safe when estimated by "feel" ranged from 9-67 mm Hg when verified with tonometry. There was less than 5 mm Hg average IOP change from immediately postop to 1-day postop IOP measurement in the clinic, and as many as 33% of postop patients without IOP adjustment in the operating theater required one day postop adjustment vs. less than 5% when an immediate adjustment of IOP was made upon case completion. Eyes with immediate postop adjustment of IOP in the operating theater had 4 times less cystoid macular edema (CME), the study found. CME was noted in 13/905 eyes (1.4%) of non-diabetics and 2 of 25 diabetics (8%). Cochrane studies showed the rate of CME in prior studies ranged from 1.2 to 4%. It also indicated that perioperative NSAIDs may not be necessary in routine non-diabetic eyes for FLACS or MICS, but perioperative NSAIDs are essential to prevent CME in diabetic patients. The investigators indicated that further studies should be done on this topic. Dr. Mamalis noted that he found this paper particularly interesting because the immediate postoperative IOP, when estimated by feel, was grossly inaccurate compared to IOP measured with tonometry.
Moving on to refractive topics, Terry Kim, MD, Durham, North Carolina, and Steve Dell, MD, Austin, shared some of their favorite refractive papers.
Dr. Kim first shared “Objective Evaluation of Patient Visual Needs for Presbyopia Correction Surgery Planning.” This study enrolled 34 healthy subjects and used the Visual Behavior Monitor (VBM, Vivior AG) technology. It concluded that understanding the patient’s lifestyle needs and visual expectations are important steps for successful presbyopia correction surgery planning, and wearable visual behavior technology can objectively capture a patient’s visual needs and may be a useful tool for surgical planning.
On the topic of cornea, Preeya Gupta, MD, Durham, North Carolina, shared papers on three topics: meibomian gland dysfunction, DMEK donor tissue, and ocular surface disease in the setting of cataract surgery. The MGD paper she shared hypothesized that thermal pulsation treatment would improve the gland structure that you can see, effectively “revitalizing” the glands. Results in the study showed improved TBUT and staining in the treatment group. In a LipiFlow (Johnson & Johnson Vision) treatment group, around 70% had an improvement in visible gland structure. Meanwhile, in the control group, 71% had worsening in the visible gland structure. The study concluded that vectored thermal pulsation treatment improved visible gland structure in most patients, and improvement in visible gland structure has never been demonstrated before.
Nathan Radcliffe, MD, New York, and Manjool Shah, MD, Ann Arbor, Michigan, wrapped up the session by sharing some of their favorite glaucoma papers.
One paper that Dr. Radcliffe shared was "Intraocular Pressure Response to Negative Pressure Applied to the Anterior Periocular Microenvironment," which he said essentially describes wearing goggles that create a vacuum to lower IOP. We know that IOP is the only modifiable risk factor for glaucoma progression, he said.
The primary endpoint was IOP reduction in the study eye compared to baseline. All subjects in the study successfully tolerated the 60-minute treatment duration, and there were no reports of discomfort or issues with tolerability. The study concluded that all 51 patients demonstrated response to the therapy. There was rapid onset of action and no rebound ocular hypertension after removal of the goggle. The googles provided lowering of IOP in normotensive patients.

Editor's note: The speakers have financial interest with a variety of ophthalmic companies.

Improving processes for refractive cataract surgery
The presentations in the ASCRS Young Eye Surgeons Saturday morning program involved ways to improve the preoperative and intraoperative processes in refractive cataract surgery.
Dr. Shah shared how he approaches his cataract surgery days but noted that as a glaucoma-anterior segment surgeon his "routine may not be routine-routine."
Setting the stage starts with prepping the patient. This, Dr. Shah said, involves establishing patient expectations, reminding them about the goals of surgery, which are safety, visual improvement, and, in some glaucoma cases, IOP and/or medication reduction. Planning for the right anesthesia, individualized to the patient’s situation, and discussing what the patient will experience during surgery is important as well.
In terms of prepping the eye, Dr. Shah said the ocular surface is hugely important as it affects reliability of diagnostic testing and IOL selection. Postoperatively, it affects visual recovery and patient satisfaction/comfort. For glaucoma patients, ocular surface preparation can affect ultimate IOP outcome.
Dr. Shah said he prefers aspheric, single-piece acrylic IOLs, taking into consideration the type of activity where the patient would like the most spectacle independence when deciding upon a monofocal or multifocal/EDOF IOL. Dr. Shah said he assumes, from the start, that everyone is a candidate for advanced technology IOLs, getting the highest testing that he can to confirm or rule out this assumption. Even if patients are not candidates, Dr. Shah explains why so they don't feel left out.
Validating your biometry by ensuring that your data makes sense (comparing it to prior spectacle prescriptions) and ensuring your staff is trained in validation can help reduce refractive surprise. Dr. Shah mentioned research that found an axial length difference of more than 0.2 mm increased risk of refractive surprise.
Tools that can give you more information include ultrasound biomicroscopy, which Dr. Shah said is helpful for suspected or known zonulopathy cases; A-scan/B-scan for cases of poor optical view or optical biometry; specular microscopy for eyes with shallow anterior chamber depth, previous angle closure, or known endothelial disease; and macular OCT for patients seeking advanced technology IOLs.
Naveen Rao, MD, Peabody, Massachusetts, tackled the topic of informed consent. There is a balance that needs to be struck between informing the patient and avoiding confusion, Dr. Rao said. But it's difficult to standardize this discussion among patients in the time available to surgeons. Dr. Rao also said that patient dissatisfaction correlates strongly with the belief that the consent process was inadequate, and an inadequate consenting process is a common reason for malpractice litigation.
Dr. Rao recommends recording yourself as you practice your informed consent spiel, trying to get it under 1 minute without talking too fast. He also recommends splitting the cataract evaluation into two visits: a dilated visit for macular OCT and to introduce concepts, expectations, provide informed consent documents, and a second undilated visit for topography, biometry, IOL options, and to sign informed consent.
Dr. Rao breaks down the rare but serious risks associated with surgery and the more common, less serious risks in his discussions. "These are the risks, but, in general, this is a good, safe surgery, and the risks outweigh the benefits," is language that Dr. Rao offered. In addition to the risks, refractive target and any limitations specific to the patient should also be discussed.

Editor’s note: Dr. Shah has financial interests with a number of ophthalmic companies. Dr. Rao does not have financial interests related to his comments.

Presbyopia-correcting IOLs: Unhappy patients and residual refractive error
"Few things are really as frustrating as this group of patients—or really as time consuming," Dr. Weikert said of patients who are unhappy after receiving a presbyopia-correcting IOL.
First, Dr. Weikert noted the importance of trying to avoid creating these unhappy patients in the first place by ensuring good candidates—based on ocular status and personality—are chosen for presbyopia-correcting IOLs. Postoperatively, residual refractive error, CME, and PCO need to be addressed, though Dr. Weikert said that PCO is rarely causing the problem.
Glare and halos caused by the lens design can be a factor for unhappiness. Most patients, given time, get used to these phenomena, but there is a subset who doesn’t. For the latter, Dr. Weikert said the doctor and the patient need to decide whether they can live with it or not.
Dr. Weikert offered the following recommendations for helping patients unhappy with presbyopia-correcting IOLs:

  • Nail distance vision in the dominant eye
  • Give time to adapt—3 months for halos, more if they're improving
  • Correct remaining refractive error
  • Hold off on posterior capsulotomy if IOL exchange is on the table
  • Monitor for capsular fibrosis to guide timing of IOL exchange
  • Exchange dominant eye first, as it may be enough to make the patient happy
  • Note that suboptimal candidates may still make it past even the most exhaustive evaluations.

Dr. Kim discussed whether IOL exchange or LASIK/PRK is the best option for residual refractive error. In many cases, Dr. Kim said he thinks LASIK/PRK is a more accurate, safer, simpler, more accessible, and more sensitive option for addressing residual refractive error. However, he noted, if you have more than 1.5 D of error, he recommends exchange. For exchange, the bag should be intact and time after the original surgery as well as any other ocular comorbidities need to be considered.

Editor's note: Drs. Weikert and Kim do not have financial interests related to their comments.

Optimizing the ocular surface
During a session about optimizing the ocular surface, Nicole Fram, MD, Los Angeles, offered her top five pearls for managing poorly healing epithelial defects.
  • Determine etiology—take a thorough history.
  • Look at the meds—change topical medications to preservative free.
  • Use amniotic membrane early in refractory disease.
  • Evaluate and treat abnormal eyelid anatomy and disease.
  • Know when a tarsorrhaphy is necessary and act quickly to avoid corneal thinning.

Also during the session, Kendall Donaldson, MD, Plantation, Florida, shared information on a number of dry eye masqueraders. She mentioned allergic conjunctivitis, which she said has many types. The treatment is different from that you would use for dry eye patients, she said, so it’s important to identify the real problem. Dr. Donaldson also mentioned superior limbic keratoconjunctivitis, noting that it’s important to look under the upper eyelid because this can go missed. Superior limbic keratoconjunctivitis can occur during upgaze, and patients often experience an alternating period of remission and exacerbation with no identifiable pattern, she said. Dr. Donaldson also discussed eyelid malposition, contact lenses, floppy eyelid syndrome, and more.

Editors’ note: Dr. Fram has financial interests with Bio-Tissue. Dr. Donaldson has financial interests with a variety 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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