EyeWorld/ASCRS reporting live from Hawaiian Eye 2020 in Kauai, Hawaii, Monday, January 20, 2020


EyeWorld/ASCRS reporting live from Hawaiian Eye 2020 in Kauai, Hawaii, Monday, January 20, 2020
Monday’s program featured sessions on a variety of cataract topics, including refractive cataract surgery, complex cases, and more.
Refractive cataract surgery

During the first morning session, Yuri McKee, MD, Mesa, Arizona, discussed managing astigmatism with the femtosecond laser during cataract surgery. Astigmatism is prevalent, he said, and he tries not to miss opportunities to treat it.

Dr. McKee highlighted how to optimize refractive outcomes, which included performing a preoperative tune-up, taking multiple measurements, and doing one’s best with patient selection, mathematics, and surgical techniques.

He also shared his rules for surgical astigmatism management:

  • All patients receive tear film optimization.
  • The cornea is examined with at least three different keratometry devices.
  • Risk factors for ectasia are examined.
  • Keratometry results are regular, repeatable, and orthogonal.

So do you use a toric IOL or AK? Dr. McKee said he will use a toric IOL if the Barrett Toric Calculator offers an advantageous toric solution. He will use AK incisions for astigmatism between 0.5–1.25 D when a toric IOL will not solve the problem. AK solves astigmatism with regular paired incisions, he said, and with a max arc length of 45 degrees and minimum diameter of 8 mm.

Dr. McKee added that he’s using the VERACITY (Carl Zeiss Meditec) for all of his IOL calculations and the Barrett integrated K for 100% of his cases.

Dr. McKee also shared his femto AK nomogram:

  • 0.5–1.25 D of corneal astigmatism
  • Consider numerous variables such as age, white to white (WTW), meridian of steep K
  • Alter arc diameter as a function of WTW
  • Keep depth stable at 80%
  • Open all incisions

Also during the session, William Trattler, MD, Miami, Florida, discussed avoiding ectasia following manual and femtosecond astigmatic keratotomy. He said it’s important to make a diagnosis of abnormal topography preoperatively, and if it’s abnormal, avoid AKs or LRIs, he said. Additionally, he said that dry eye is very common and can make accurate imaging difficult. Topography abnormality may be subtle, Dr. Trattler said, and a femto AK may tip a patient over to ectasia.

Vance Thompson, MD, Sioux Falls, South Dakota, discussed trifocal IOLs and shared some practical tips for the recently FDA-approved PanOptix trifocal (Alcon).

We’ve gotten by so far with mixing and matching for distance, intermediate, and near vision, Dr. Thompson said, but it doesn’t work all the time. The PanOptix has a near point at 40 cm and an intermediate at 60 cm. Dr. Thompson shared some of his results as part of the FDA trial, as well as after the lens’ approval, adding that he’s never seen a clinical trial that had such high patient satisfaction.

He also shared several tips for success with the PanOptix. One was to get 360 degrees of capsular overlap with the capsulorhexis. Another was to understand the refractive workup and be able to get a topography. Finally, he said with previous corneal refractive surgery, you have to think about what light scatter is going on and if the patient will need a fine tune.

Editors’ note: Dr. McKee has financial interests with Carl Zeiss Meditec, Ivantis, and LENSAR. Drs. Trattler and Thompson have financial interests with various ophthalmic companies.

Patient perceptions of cataract surgery

Another session on Monday morning focused on miscellaneous cataract topics. Terry Kim, MD, Durham, North Carolina, discussed his study comparing patient perceptions of first and second eye cataract surgery.

He first shared several videos from his patients, indicating that they were more aware during the surgery on their second eye. This prompted Dr. Kim to evaluate patient perceptions of second eye cataract surgery compared to first eye in terms of preop, intraop, and postop awareness of events, level of discomfort, and comparison of awareness between the first and second eye. The study, so far, has been conducted on cataract surgeries done by Dr. Kim between April and November 2019. Patients were given a voluntary questionnaire. The study is ongoing, with 269 patients surveyed so far (148 first eyes and 121 second eyes, including 69 patients who underwent first and second eye surgery during the study period).

Preliminary results showed no significant difference between recall of preop, intraop, or postop events between first and second eye surgery. Patients had more discomfort on average after their second eye, however, there was no statistically significant difference between discomfort levels for the first and second eye.

Dr. Kim said that 64.2% of patients remembered more events from their second surgery, and only 8.3% remembered more events from their first surgery. Patients whose surgeries occurred closer together temporally seemed more likely to recall the second surgery as more uncomfortable, he said.

Looking at the literature, Dr. Kim said there is only one paper in peer-reviewed literature that addresses this topic, and it also notes no statistically significant difference in the factors they were looking at.

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

Complex cases

The final session of the Monday morning cataract program looked at a variety of complex cases.

Marjan Farid, MD, Irvine, California, shared some of the benefits of femtosecond laser-assisted cataract surgery for complex cases. She stressed that there is less ultrasound energy going into the eye and less nuclear manipulation. She also mentioned capsule centration of the capsulotomy and customizable AK incisions for astigmatism management as two advantages. Particular complex cases when it may be helpful to use this technology include dense cataracts, Fuchs and post PKP patients, zonulopathy, and complex asymmetric astigmatism, Dr. Farid said.

Also during the session, Elizabeth Yeu, MD, Norfolk, Virginia, shared some pearls for success when managing mature brunescent lenses.

Pearl 1: Understand your opponent.

If you’re looking at a brunescent lens, ocular history is very important, she said. It’s important to know about any previous trauma, pars plana vitrectomy, etc.

Pearl 2: Consider needle compression if there is any intumescence under the anterior capsule.

Pearl 3: Differentiate settings for nuclear disassembly.

Dr. Yeu said to separate the chop setting to engage and lift pieces out of the bag. She also said to separate the quadrant setting to disassemble freed fragments.

Pearl 4: Take your time to fragment your nucleus into at least 6–8 fragments.

Chop and re-chop, Dr. Yeu said, and use repeated dispersive viscoelastic protection (after each quarter).

Pearl 5: Advanced technology and devices can be helpful.

Dr. Yeu said that femtosecond laser-assisted cataract surgery can soften brunescent lenses, but it does not do much for mature brunescent lenses. The miLOOP (Carl Zeiss Meditec) may be very helpful in these cases.

Pearl 6: The posterior capsule needs extra protection.

Editors’ note: Drs. Farid and Yeu 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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