EyeWorld/ASCRS reporting live from Hawaiian Eye 2020 in Kauai, Hawaii, Tuesday, January 21, 2020


EyeWorld/ASCRS reporting live from Hawaiian Eye 2020 in Kauai, Hawaii, Tuesday, January 21, 2020

Tuesday’s program included more content on cataract surgery, including the ‘Cataract Surgery Complications: You Make the Call’ session, where video complications are presented and panelists and audience members are asked to weigh in on how they would respond in various scenarios.

Current controversies in cataract surgery

A Tuesday morning session looked at several “current controversies” in cataract surgery, highlighting improving medication compliance after cataract surgery, presbyopia-correcting IOLs, and combined phaco-MIGS procedures.

One debate in the session was between what is the best MIGS procedure with phaco.

Thomas Samuelson, MD, Minneapolis, Minnesota, argued that he prefers phaco and canal-based surgery. He said to keep in mind that there may be more than one good option.

Cataract surgery lowers IOP, at least modestly, for most patients with mild to moderate glaucoma and elevated IOP, Dr. Samuelson said. In the setting of moderate glaucoma, you have to think about which procedure is least likely to disrupt normal anatomy and normal function and least likely to cause a fibrotic healing response long term, he said.

Dr. Samuelson stressed that, if a patient has mild to moderate glaucoma, and if phaco alone has already helped some, he is reluctant to dramatically alter normal anatomy and physiology. He added that longer term data (more than 6–12 months) is needed to be certain that anatomic disruption inherent to extensive goniotomy is not causing longer term fibrosis. For now, Dr. Samuelson said he likes the minimalist approach of canal devices when combined with phaco.

On the other side, Malik Kahook, MD, Aurora, Colorado, made the case for goniotomy.

In terms of goniotomy, Dr. Kahook argued that it is both safe and effective. Excisional goniotomy is the second most common glaucoma procedure performed in the U.S. today, he said, and dozens of studies have shown an excellent safety protocol. The blood reflux at the time of trabecular meshwork excision is transient and a sign of distal patency, he said.

Dr. Kahook also stressed that there are over 25 publications across different practices (company-sponsored and independent studies) showing efficacy. This option reduces IOP by 24–36% and medication burden by 37–70% through long-term follow-up, he added. There are also favorable results in combined and standalone, mild to end-stage, and primary to secondary glaucomas, Dr. Kahook said.

He added that he chooses excisional goniotomy for the reliability and versatility without leaving an implant behind or worrying about reimbursement.

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

‘Cataract Surgery Complications: You Make the Call’

David Chang, MD, Los Altos, California, moderated this session, with panelists Brandon Ayres, MD, Philadelphia, Pennsylvania, Arthur Cummings, MD, Dublin, Ireland, Uday Devgan, MD, Los Angeles, California, Marjan Farid, MD, Irvine, California, Florian Kretz, MD, Rheine, Germany, Jennifer Loh, MD, Miami, Florida, Kevin Miller, MD, Los Angeles, California, Randall Olson, MD, Salt Lake City, Utah, Kerry Solomon, MD, Mount Pleasant, South Carolina, and Audrey Talley-Rostov, MD, Seattle, Washington.

The first case Dr. Chang shared was a rock hard cataract in a 79-year-old patient. Dr. Chang had already operated on the “better” of the two eyes and was now going to attempt the more brunescent lens.

He asked the audience and panelists to weigh in on their preferred capsulotomy approach. Audience members overwhelmingly (76%) indicated that they would use a manual approach with dye, and 16% said they would do a femto capsulotomy.

Dr. Loh said she thinks the surgeon would have multiple options and noted that she would definitely use dye if she was choosing a manual approach. She also said that femto or Zepto (Mynosys) would work in this scenario.

Dr. Chang continued with his case, choosing to do manual with dye. However, he noted that he was seeing a lot of movement and was having trouble seeing, which he called “an ominous sign.”

He next asked audience members how they would handle phacodonesis, with 37% indicating that they would commence careful phaco and 39% saying they would use capsule retractors and phaco.

Dr. Miller said he does not find a CTR to be helpful with stabilization in this case, so he would use a retractor or sculpt very gently to not disturb the zonules.

Moving on, Dr. Chang asked about converting to ECCE. Most audience members said they would do a temporal limbal incision (33%) or use miLOOP (Carl Zeiss Meditec) and perform small incision ECCE (30%).

Dr. Kretz said that he would likely start with the miLOOP in this case. Dr. Loh also stressed caution with the miLOOP, if there is a lot of zonular weakness.

Ultimately in this case, Dr. Chang moved forward with ECCE, indicating that part of the reason was because his patient had already done so well in the other eye.

He then called attention to the hard lens he had taken out, noting that the nucleus was flat in the front and concave in back. This shows how hard it is to chop, Dr. Chang said.

Dr. Chang also shared two cases where the patients had cataracts and hated glasses. Both cases involved numerous lens choices, changes to the plan, and many follow-ups postoperatively.

In one case of a 54-year-old who hated glasses, audience members indicated that they might recommend a multifocal (38%), an EDOF (23%), or a monofocal with slight myopia (28%).

This patient may do well with EDOF with some counseling, Dr. Farid said. Other panelists suggested that the PanOptix trifocal (Alcon) may be a good choice.

When deciding between an EDOF and trifocal lens, Dr. Talley-Rostov said that she would talk to the patient about specific visual needs. If the patient is used to wearing contact lenses and just having distance vision, they may do fine with EDOF, she said, adding that she thinks that super high myopes will be a little more understanding that there may not be the perfect lens for them.

Editors’ note: The speakers have financial interests with a variety of ophthalmic companies.

Combining cataract surgery with other surgery

During the final Tuesday morning session, Inder Paul Singh, MD, Racine, Wisconsin, discussed combining glaucoma and cataract surgery. He mentioned several reasons why cataract surgeons are well suited for MIGS procedures. They see more mild to moderate patients; reducing the medication burden safely can help the ocular surface and quality of vison post-cataract surgery; MIGS requires similar skills as cataract surgery; and earlier intervention is desirable.

The problem we have now is there are so many options in MIGS, Dr. Singh said. He said he breaks it down by the conventional outflow pathway that’s easiest to incorporate during cataract surgery. Options may include outflow stents (approved at the time of cataract surgery), dilation of the outflow system (approved with cataract surgery or as a standalone procedure), and trabecular meshwork stripping/removal (approved with cataract surgery or as a standalone procedure).

Dr. Singh also stressed that the most important process is understanding gonioscopic skills and that IOP reduction is not just from phaco.

Editors’ note: Dr. Singh 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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