March 2019


EyeWorld/ASCRS reports from the 2019 Hawaiian Eye Meeting

EyeWorld/ASCRS reports from the 2019 Hawaiian Eye Meeting, January 19–25,
Big Island of Hawaii

View videos from the 2019 Hawaiian Eye:

Elizabeth Yeu, MD, discusses the prophylactic management of herpetic eye disease in preparing for cataract/refractive surgery.



Wendy Lee, MD, Miami, covered common eyelid malpositions in her presentation. It’s important to remember the primary function of eyelids is to protect the globe and ocular surface, she said. If the lids don’t perform well, this can endanger the underlying structure, which could lead to other complications. 
The two most common malpositions are ectropion and entropion. 
With ectropion, Dr. Lee said the most common cause is involutional, and this can cause tearing, foreign body sensation, exposure, or conjunctival inflammation. 
For entropion, Dr. Lee said the most common cause is also likely involutional. Complications can include corneal and conjunctival abrasions, foreign body sensation, redness, tearing, and discharge. Dr. Lee said to be sure to differentiate among trichiasis, distichiasis, and epiblepharon on evaluation. 
Also during the session, Dr. Lee presented on behalf of Eli Chang, MD, Long Beach, California, on “Removing Annoying Eyelid Barnacles and Reconstructing If Necessary.”
You need to start by looking at the lesions and formulating in your mind if you think it’s benign or malignant, Dr. Lee said. 
She said to look at history and determine how long the lesion has been there, if it has been growing, if there are any systemic conditions, and the sun exposure and skin type of the patient.
Generally, with a benign lesion, Dr. Lee said it’s well outlined, there is no loss of lashes, and there is no loss of normal skin architecture. Her personal approach is to do an excisional biopsy, but she will still have the lesion checked to confirm that it is benign.
Malignant lesions will usually cause loss of lashes, nodularity, telangiectasia, and loss of normal skin architecture. Dr. Lee said she will get a confirmatory biopsy if she thinks it’s malignant. 
Among the options for skin cancer removal, Dr. Lee stressed surgical excision with a permanent section, surgical excision with a frozen section, and Mohs micrographic surgery. The ultimate goals for management of skin cancer are complete removal, no recurrence, no postoperative complications, and minimal loss/damage to the surrounding tissues.

Editors’ note: Dr. Lee has no financial interests related to her presentations.

Special guest speaker

The special guest speaker at the meeting was Ron Jaworski, a 17-year veteran NFL quarterback, sports broadcaster, business owner, and philanthropist.
Mr. Jaworski shared his football history and how this gave him a foundation to carry over to his experiences in business.
He highlighted the importance of building a team, noting that this is something attendees can relate to. He stressed the importance of discipline to believe that the leadership will set you up for success. Trust was another important principle that Mr. Jaworski discussed. He highlighted the importance of trust in football and likened it to the trust physicians need to have among their staff.
Mr. Jaworski shared his “Seven no-brainers of leadership”:
1. You must like people. 
2. You must lead by example. 
3. Create an atmosphere where people enjoy coming to work. 
4. Bring energy. 
5. Look people in the eye and let them know you care and create that relationship.
6. Be sincere. 
7. Define the goal, delegate, and lead.

Refractive IOLs and femto laser- assisted cataract surgery

Preeya Gupta, MD, Durham, North Carolina, presented on manual vs. femto arcuate incisions. She noted that 52.5% of patients with cataracts have more than 0.75 D of clinically significant preexisting corneal astigmatism.
For preop planning, Dr. Gupta highlighted three main steps: make sure the astigmatism is regular (avoid irregular astigmatism), rule out any confounding corneal pathology (avoid in ABMD, Salzmann’s nodules, pterygium), and plan treatment based on a nomogram (always make the incision on the steep axis).
Dr. Gupta shared reasons why surgeons may switch from manual to femto incisions. Femto corneal incisions have precise depth and placement, continuous curvature, and offer the ability to titrate the incision, which does not disrupt the epithelium and you can open the incision after surgery.
Dr. Gupta also mentioned some of the key differences between femto and manual incisions. Femto is photodisruptive (the incision architecture is different from manual); you can’t use the same nomograms (you will get overcorrection if using a manual nomogram with femto); and centration is the most critical step in femto because decentration can be an issue.
Dr. Gupta said there is not enough evidence to say one is better than the other at this point. However, her personal preference is to use the femtosecond laser to create an incision because it offers increased efficiency at the time of cataract surgery; it’s more predictable in her hands; and it makes her think about treating astigmatism in all cases.
In summary, Dr. Gupta said that the femtosecond laser and the manual technique are both excellent options for creating arcuate incisions in astigmatism correction. 

Editors’ note: Dr. Gupta has financial interests with a number of ophthalmic companies.

IOL fixation without capsular support and learning the Yamane technique 

Brandon Ayres, MD, Philadelphia, discussed options for IOL fixation without capsular support.
He shared tips for using iris fixation, which he said is helpful to fixate a three-piece IOL and is minimally invasive. He said a 10-0 polypropylene suture on a curved needle is best and recommended passing the suture “into the curve” of the haptic, which will help gather the iris. The suture can be tied with a McCannel or Siepser sliding knot. 
Though safety has been established with iris fixation, it is not without difficulty and complications, he said. Issues like ovalization, hemorrhage, macular edema, and repeat dislocation could occur.
Dr. Ayres also discussed scleral suture fixation. The use of Gore-Tex sutures and IOL are off label. Suture fixation gives excellent four-point stability, he said, but you must not overtighten the suture. Knots must be buried into the sclera to avoid exposure. Dr. Ayres added that hydrophilic acrylic material can lead to problems.
Lastly, Dr. Ayres highlighted haptic fixation. He said to measure twice and make sclerotomies once. You must use a thin-walled, 30-gauge or 27-gauge needle. He said one should watch the oxygen when using cautery. 
Also during the session, Zaina Al-Mohtaseb, MD, Houston, shared pearls for learning the Yamane double-needle technique.
• Use a special large lumen 30-gauge needle. 
• Place the needle on a non-luer locked TB syringe filled with balanced salt solution (not too tight).
• Test the haptics in the needles prior to lens insertion. 
• An AC maintainer can be helpful, especially in vitrectomized eyes. 
• Mark the conjunctiva at 1 and 7 o’clock (exactly 180 degrees apart) 2 mm posterior to the limbus. 
• Stabilize the globe using a 0.12 near area of needle insertion. 
• Insert the needle a bevel and a half (2 mm) in the sclera prior to turning centrally.
• Bend 25-gauge MaxGrip forceps. 
• Use low-temp cautery to create flanged haptic.
• You can use any three-piece lens, but the haptics’ angle and ends differ.
• Grab the proximal haptic parallel instead of perpendicular.

Editors’ note: Dr. Al-Mohtaseb and Dr. Ayres have financial interests with a number of ophthalmic companies.

Complicated cases

Kendall Donaldson, MD, Plantation, Florida, discussed how to handle soft cataracts. Some of the “dangers” of soft cataracts include inability to crack or chop easily, bowling out the nucleus, creation of a posterior sheet of residual lens material, false confidence, and high expectations. 
Dr. Donaldson suggested considering a slightly larger capsulotomy, allowing flip and carousel. She also said that changing your second instrument to use a Drysdale nucleus manipulator or Koch spatula could help. She said not to pre-judge based on the size of the cataract.
Cynthia Matossian, MD, Doylestown, Pennsylvania, presented on alternative drug delivery options for cataract surgery.
Compliance is a major issue. Around 93% of patients improperly administer drops following cataract surgery. The number of doses required following cataract surgery is high, and it can be a burden for patients to keep track of. 
There is a new era of being able to deliver drugs at the time of cataract surgery, Dr. Matossian said. She mentioned a number of methods. The first was transzonular injection, but Dr. Matossian noted this is not FDA approved and there is a learning curve. Pars plana injection is another option, but Dr. Matossian pointed out that this is an additional step, there is a learning curve, and there is some pain.
Dr. Matossian mentioned intracameral products, which are a familiar landscape, require no additional instruments, and are quick. However, the problem is they’re not FDA approved.
Dr. Matossian mentioned two FDA-approved products: Dexycu (dexamethasone intraocular suspension, EyePoint Pharmaceuticals, Watertown, Massachusetts), which can be administered over a 30-day period, and Dextenza (dexamethasone ophthalmic insert, Ocular Therapeutix, Bedford, Massachusetts).

Editors’ note: Dr. Donaldson and Dr. Matossian have financial interests with a number of ophthalmic companies.

Cataract surgery complications: “You make the call”

A session featured a variety of complicated cataract surgery case videos, with audience members and panelists weighing in on how they would handle different aspects of the case. David Chang, MD, Los Altos, California, moderated and presented the video cases.
The first panel consisted of Florian Kretz, MD, Heidelberg, Germany, Kerry Solomon, MD, Mt. Pleasant, South Carolina, Jay Pepose, MD, PhD, Chesterfield, Missouri, Audrey Talley Rostov, MD, Seattle, and John Hovanesian, MD, Laguna Hills, California.
Dr. Chang presented a case of a cataract patient who was a computer engineer, a myope, and hated glasses. Dr. Chang asked the audience what they would recommend for the patient who dislikes glasses, and 30% indicated that they would generally choose monofocal monovision. Additionally, 18% chose a diffractive multifocal IOL and 24% chose a diffractive EDOF IOL, while 20% said they would combine these two options. 
Dr. Solomon said he might first test the patient with contact lenses for monovision to see if he could tolerate it. 
Dr. Chang asked the audience the same question again after presenting more details on his specific patient, indicating that the patient was very visually demanding and described himself as nearly a perfectionist. Audience members still largely (39%) chose monofocal monovision, and 41% said they would now refer this patient. 
Dr. Hovanesian said he might try a low-add multifocal and added that he has had great success with the Crystalens (Bausch + Lomb, Bridgewater, New Jersey) in patients like this. The Crystalens was ultimately what Dr. Chang chose.
In addition to being visually demanding, complications that came up with this patient were postop refractive shift and Z syndrome. Dr. Chang asked audience members how they would manage Z syndrome, and 40% indicated they would YAG the posterior capsule. 
Dr. Hovanesian said that since the posterior capsule is still intact, that’s something to address. He said he would not choose to do an IOL exchange. The issue isn’t with clarity as with range of vision, which can be adjusted with an excimer laser. However, he noted that this would be the second procedure, and he would first do a YAG.
Dr. Chang also cautioned that if you YAG and it doesn’t work, you cut out the idea for an IOL exchange. 
The second panel of the session consisted of Thomas Samuelson, MD, Minneapolis, Richard Lindstrom, MD, Minneapolis, Randall Olson, MD, Salt Lake City, Kevin Miller, MD, Los Angeles, and William Trattler, MD, Miami. One case they commented on was a white lens in a 16-year-old uveitis patient. 
Dr. Chang asked what IOL material would be best in a young uveitis patient. Audience members overwhelmingly (70%) chose hydrophobic acrylic, and Dr. Olson added that this is recognized to be the safest option. 
During Dr. Chang’s case, an anterior chamber tear occurred, which he noted was likely because he overfilled one side and pushed the cortex to one half of the capsular bag, causing it to split.
To handle an anterior chamber tear, half of the audience indicated they would attempt to rescue one side, while about a third (34%) said they would convert to can opener. 
Attendees were also asked which lens they would implant in this scenario. Thirty-nine percent chose a single piece acrylic toric in the bag. 
Dr. Trattler agreed a toric IOL could be an option for this patient, and Dr. Samuelson said that he would choose a toric if the haptic orientation was in an optimal position.
Dr. Olson said he might be leery of a toric under these circumstances because it’s not uncommon for the haptic to rotate and pop into the area of weakness. 
For this patient, Dr. Chang ultimately chose a toric lens.

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

Achieving high patient satisfaction with presbyopic IOLs

Kendall Donaldson, MD, Plantation, Florida, presented on monovision as an alternative to presbyopia-correcting IOLs. She first shared some “facts and fallacies about monovision.” Two myths are that (1) monovision is no longer fashionable, and (2) more expensive presbyopia-correcting IOLs have replaced monovision. Two facts, she said, are that (1) monovision predates multifocal and accommodating IOLs, and (2) monovision still survives and is the most common form of presbyopia correction.
When choosing a near target, Dr. Donaldson suggested targeting more anisometropia in patients with prior monovision (–1.5 to –2 D)
and targeting mini-monovision in those new to monovision (–1.25 to –1.5 D).
When and why is monovision the best option? Certainly, there’s a cost aspect, she said. Monovision can go through the patient’s insurance, and it’s cheaper than some of the premium options. It could also be an option if the patient has a history of enjoying monovision; if the patient is highly motivated and not willing to accept dysphotopsias; and if the patient does not require a high degree of depth perception. 
Some of the benefits of monovision are it maintains quality of vision; it’s easy to simulate with contact lenses; you can avoid unpredictable dysphotopsias; it provides a high degree of spectacle independence; studies support a high level of patient satisfaction; you may avoid loss of contrast sensitivity; monovision is less dependent on the ocular surface compared to multifocals; and it’s inexpensive. 
There are some limitations, including potential loss of stereopsis, each eye is dedicated to a different focal point, and some patients may not adapt. 
Dr. Donaldson shared her “3 keys to successful monovision”:
1. Choose your patients wisely. 
2. Set accurate expectations before surgery. 
3. Do a trial before surgery. 

Editors’ note: Dr. Donaldson has financial interests with a number of ophthalmic companies.

The SALT trial

Jeffrey Goldberg, MD, Palo Alto, California, presented on the Steroids After Laser Trabeculoplasty (SALT) trial. The purpose of the study was to determine whether short-term use of steroids or NSAIDs affects the efficacy of selective laser trabeculoplasty (SLT).
The study was a double-masked, randomized, placebo-controlled clinical trial conducted at the Bascom Palmer Eye Institute and the University of Pittsburgh Medical Center Eye Center (and analyzed by the University of California, San Diego and Stanford University). The primary outcome was IOP lowering of each group versus placebo at 6 and 12 weeks, with secondary outcomes of anterior chamber reaction and ocular discomfort. 
Participants were double masked and randomized to three groups: ketorolac 0.5%, prednisolone 1%, and saline tears. All groups were asked to use their drop four times daily for 5 days, where the first day was the day of SLT. 
Dr. Goldberg said all patients were pretreated with one drop of apraclonidine immediately before the laser treatment, and 180 to 360 degrees of the angle was treated with SLT using 50 to 100 non-overlapping applications, with a spot size of 400 µm (centered on the trabecular meshwork) and pulse duration of 3 ns. The initial energy used was
0.8 mJ, and the energy was titrated to champagne bubble formation. 
The study ended up including 96 eyes of 85 patients and there was no difference in baseline IOP among the three groups.
Dr. Goldberg said that at 6 weeks, there was a trend toward better IOP lowering in the non-steroidal and steroid groups compared to the saline tears group. This trend became statistically significant at 12 weeks.
For the secondary outcomes, there was no inflammation past 1 hour, with no difference between groups. 
Dr. Goldberg noted that the study had some limitations, including a small sample size and a short follow-up period. There need to be repeated studies to generate confidence in the results. 
In summary, he said that the trial showed that both NSAIDs and steroids resulted in improved IOP lowering compared to placebo. He noted that this can potentially be applied to practice now.

Editors’ note: Dr. Goldberg has financial interests with a number of ophthalmic companies.

Medical cornea panel

A panel focusing on medical cornea included moderators Preeya Gupta, MD, Durham, North Carolina, and Francis Mah, MD, La Jolla, California, with panelists Kendall Donaldson, MD, Plantation, Florida, Marguerite McDonald, MD, Lynbrook, New York, Lisa Nijm, MD, Warrenville, Illinois, Priyanka Sood, MD, Atlanta, William Trattler, MD, Miami, and Helen Wu, MD, Boston.
Dr. Sood shared a case of a 68-year-old man who presented with blurry vision since his cataract surgery at an outside hospital. He denied any pain, flashes, floaters, or veils of vision loss. On exam, Dr. Sood discovered a central detachment of Descemet’s membrane.
Interestingly, within a month of this patient presenting, she had another patient with the same problem. A 71-year-old female patient presented with clouding vision, and she also denied flashes, floaters, or veils of vision loss. The patient’s exam also showed central Descemet’s detachment. 
In both cases, Dr. Sood said there didn’t seem to be any corneal edema. Anterior segment OCT can help show the height of detachment.
The ultimate goal in these situations is reattachment. If you can get reattachment, you’ll decrease the risk of pigment clumps and significant visual disturbances, she said. 
However, both of Dr. Sood’s patients had pigment clumps already, so she didn’t think that reattachment would help. In both cases, she ended up doing descemetorhexis of that small area. In the long term, the patients did well.
Dr. McDonald presented a case of a 13-year-old girl who had taken her mother’s credit card and ordered blue tinted contact lenses from the internet. The lenses were not FDA approved, and the girl had no fitting session with an optometrist or ophthalmologist. The patient wore the lenses for a few hours on two consecutive days and developed pain and loss of visual acuity. She was managed for 2 days before being referred to Dr. McDonald for poor response to topical lubrication and antibiotics. 
The patient had severe photophobia and was in agonizing pain. She also had non-healing epithelial defects. 
Dr. McDonald noted that the left eye healed, but the right eye would not, so she put an amniotic membrane in and initiated serum tears. The first amniotic membrane dissolved quickly, and an amniotic membrane was reinserted 3 days later. 
The patient ended up needing a tarsorrhaphy, Dr. McDonald said, and 8 days later, there was complete healing. Four months and 1 week after first presenting, the patient returned to 20/20 uncorrected on no medications. 
One problem with this case, Dr. McDonald said, is that the girl was able to order the lenses online without consulting a doctor. She stressed the importance of reporting sites that sell these types of unapproved lenses to the FDA.

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

Surgical cornea panel

The second panel featured moderators Sumit “Sam” Garg, MD, Irvine, California, and Elizabeth Yeu, MD, Norfolk, Virginia, with panelists Zaina Al-Mohtaseb, MD, Houston, Brandon Ayres, MD, Philadelphia, John Berdahl, MD, Sioux Falls, South Dakota, Alan Faulkner, MD, Honolulu, Sumitra Khandelwal, MD, Houston, and Sonia Yoo, MD, Miami. 
Dr. Khandelwal shared a case of OSD conjunctivochalasis. This is an under-represented diagnosis, she said, and patients often present with epiphora, dry eye, and other symptoms where nothing seems to work. Panelists agreed that this is something they see quite a bit. 
Dr. Faulkner said that many of his patients with this problem present purely with tearing, and many note that the problem is worse in down-gaze reading. 
Conjunctivochalasis is a growing condition, Dr. Khandelwal said, and, it’s seen more in scleral lens wearers. 
She noted several approaches for management: focal cauterization, diffuse cauterization, and surgical excision.

Editors’ note: The panelists have financial interests with a number of ophthalmic companies.

EyeWorld/ASCRS reports from the 2019 Hawaiian Eye Meeting EyeWorld/ASCRS reports from the 2019 Hawaiian Eye Meeting
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