EyeWorld/ASCRS reporting live from ASCRS Winter Break in Park City, Utah, Thursday, January 30, 2020


EyeWorld/ASCRS reporting live from ASCRS Winter Break in Park City, Utah, Thursday, January 30, 2020
The ASCRS Winter Break meeting kicked off on Thursday in Park City, Utah, with presentations covering a variety of challenges and controversies in cataract surgery and providing valuable surgical pearls.
Challenges and controversies in cataract surgery

During the first session of the day, Elizabeth Yeu, MD, Norfolk, Virginia, discussed the evolving approach to astigmatism management, sharing a number of pearls.

Pearl 1: Identify real vs. false causes of corneal astigmatism.

Pearl 2: Confirm quality using Placido disk topography; confirm quantity (axis, amount) with at least two devices.

Pearl 3: Remember refractive astigmatism is more than what is in the anterior cornea.

Pearl 4: Take advantage of advanced online toric calculators and toric IOL formulas.

Pearl 5: When available, choose a toric IOL over LRI/AK to correct for corneal astigmatism.

Dr. Yeu stressed that refractive astigmatism is affected by both the anterior and posterior cornea, as well as IOL tilt, effective lens position, and surgically induced astigmatism. She also mentioned the Barrett Toric Calculator (available online) as an “essential tool” for astigmatism correction with toric IOLs.

Surgical options to correct corneal astigmatism are expanding, Dr. Yeu said, including technologies like presbyopia-correcting toric IOLs and the Light Adjustable Lens (RxSight).

Preeya Gupta, MD, Durham, North Carolina, discussed the future of femto. The femtosecond laser was FDA approved for cataract surgery a decade ago, she said.

Dr. Gupta said that she likes femto for astigmatism management, and it makes her think about astigmatism in every patient.

The femtosecond laser provides a reproducible capsulotomy that can be precisely placed on the anterior capsule; it allows for decentration, if needed; modern updates to the laser have a lower risk of tags and anterior capsule tears; and it helps with lens fragmentation.

Dr. Gupta referenced a recent paper that showed that postoperative astigmatism was reduced when making femto arcuate incisions, and she also mentioned some of her unpublished data comparing femto surgery with arcuate incisions to conventional surgery. Her data found that more patients were seeing 20/20 postop in the patients with femto with arcuate incisions compared to conventional surgery.

However, there are still some notable cons of the femtosecond laser, Dr. Gupta said, including the cost, the learning curve, and complications.

The effect of the cost really depends on the practice, Dr. Gupta said. It can be cost prohibitive to new users, she said, and the business model does not lend itself to limited use of the femtosecond laser. She added that sales have not dramatically increased over the last 5–7 years.

Dr. Gupta also discussed some of the potential complications, referencing a meta-analysis that found there was a greater relative risk of incomplete capsulotomy, anterior capsulotomy tag, and anterior capsule tear with femto.

In terms of complications, Dr. Gupta said she thinks “the jury is still out.” There seems to be some mismatch in the literature to personal experiences, she said. Capsulotomy nuances and energy managements are relevant when learning femto, she added.

In conclusion, she said that femto-assisted cataract surgery still has a role, but some may perceive different values. Femto has value in astigmatism management, especially in low levels of corneal astigmatism, she said, adding that future iterations should address concerns about cost, complications, and functionality.

Editors’ note: Drs. Gupta and Yeu have financial interests with a variety of ophthalmic companies.

Pearls in cataract surgery

The second session of Thursday’s program featured presenters sharing pearls on a variety of topics in cataract surgery.

Sumit “Sam” Garg, MD, Irvine, California, shared pearls about IFIS.

Pearl 1: Ask the right questions. You want to know if your patient is at risk for IFIS, he said, so go through the chart and also ensure they’re not on certain medications. Tamsulosin and alpha antagonists can be associated with IFIS, he said.

Pearl 2: Be prepared. When you go into these cases, have the stuff you think you might need in the room and available to you, he said, adding that he likes to do a “squirt test” to see if the “iris is jumping a little bit.” He also recommended iris expanders.

Pearl 3: Incision management. Dr. Garg recommended anterior incisions, a longer incision, and a low threshold to suture.

Pearl 4: It’s not just for men. IFIS may occur in females as well, Dr. Garg said. Alpha 1 blockers are used for benign prostatic hyperplasia, but they are also used for urinary retention in women and commonly used for kidney stone management, he said.

Pearl 5: Pressure management. You want to make sure the pressure is equalized, he said, mentioning gradient, hydrodissection, and low-flow phaco. Dr. Garg said it’s also important to come off the infusion before coming out of the eye.

Douglas Koch, MD, Houston, Texas, discussed IOL calculations. The literature shows that around 70–80% of surgeons are within 0.5 D of predicted IOL calculations, but this also gets worse in complex eyes, Dr. Koch said.

Sources of error, he continued, may include effective lens prediction (ELP), the cornea (both anterior and posterior cornea), and refraction. The new biometers do a fantastic job with axial length and in the cornea (for healthy corneas), Dr. Koch said.

So how do you calculate power? Dr. Koch said geometric optics, ray tracing, artificial intelligence, or combination formulas can be used.

The common goal is to either directly or indirectly predict ELP, he said. OCT may be used preoperatively or intraoperatively. Despite improved ELP prediction, Dr. Koch said there’s no evidence that this results in more accurate IOL calculations. ELP can also shift unpredictably postoperatively, he added.

In addition to normal eyes, there are other special considerations that make IOL calculations more difficult. Short eyes are more challenging, Dr. Koch said, though he noted that there is much improvement in calculations in long eyes. He mentioned the Wang-Koch modification of axial length and said ELP has less of an impact on the outcome in long eyes.

Dr. Koch also highlighted considerations for post-LASIK eyes and keratoconus.

In summary, to obtain better IOL calculations, Dr. Koch stressed the importance of using accurate devices, using the best formulas, verifying data, and educating patients about the fallibility of the calculations.

Nathan Radcliffe, MD, New York, New York, shared a number of pearls relating to MIGS.

His first was to use trypan for visualization. This can be used to stain the trabecular meshwork as well as the capsule, he said.

His next pearl related to “new stents on the block.” He mentioned both the iStent inject (Glaukos) and the Hydrus Microstent (Ivantis) as good options. Dr. Radcliffe called the iStent inject the “pinnacle of minimally invasive,” but he noted that it’s up to the surgeon to ensure correct placement of the stent. Meanwhile, the Hydrus is slightly larger, he said, so you know for sure if you did or didn’t get it in the right place.

He also mentioned non-stent options as another pearl and said that he sees room in every practice for both stent and non-stent options.

Dr. Radcliffe highlighted endoscopic cyclophotocoagulation (ECP) for combo procedures and the XEN Gel Stent (Allergan) ab externo.

Editors’ note: Drs. Garg, Radcliffe, and Koch have 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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