March 2019


EyeWorld/ASCRS reports from the 2019 Surgical Summit

EyeWorld/ASCRS reports from the 2019 Surgical Summit,
January 31–February 2, Park City, Utah

View videos from the 2019 Surgical Summit:

Douglas Koch, MD, discusses how IOL calculation challenges are being met.

View videos from the 2019 Surgical Summit:

Nicole Fram, MD, argues that DMEK is worthwhile even in complex cases.


IOL calculations

Mitchell Weikert, MD, Houston, presented “IOL Calculations: Axial Length to the Extreme.”
Most modern formulas perform well “on average,” Dr. Weikert said, noting that about 71% of eyes are within ±0.5 D and about 93% of eyes are within ±1 D. However, formulas perform less reliably at extremes of axial length. In short eyes, the formulas tend to overestimate the required IOL power (leading to myopic error), and in long eyes, they tend to underestimate (leading to hyperopic error).
In long eyes, his approach is to use the Holladay 1 (with adjusted axial length) or Barrett formula and aim for very slight myopia. Dr. Weikert said he will operate on the nondominant eye first because it is more tolerant of myopic error with adjusted axial length, and he will factor the RPE of the first eye into the IOL choice for the fellow eye. 
In short eyes, Dr. Weikert will use either the Holladay 1 or 2 formula, the Hill-RBF, the Barrett formula, or the Olsen formula. He will lean toward the Olsen when the formulas disagree. In short eyes, Dr. Weikert said he would also operate on the nondominant eye first because it’s more tolerant of myopic error, and he can again factor in the RPE of the first into the IOL choice for the fellow eye. 
Dr. Weikert said one question that remains is whether there will be improved results in these cases with segmented axial lengths.

Editors’ note: Dr. Weikert has financial interests with Alcon (Fort Worth, Texas) and Ziemer (Port, Switzerland).

Capsule strength in complex FLACS cases

Nicole Fram, MD, Los Angeles, discussed femtosecond laser-assisted cataract surgery (FLACS), saying that while she thinks it is comparable to conventional cataract surgery in routine cases, it could be useful in specific eyes and could make complex cases more manageable. The controversy, she said, is whether the femtosecond-created capsulotomy is strong enough to handle the hooks and rings that could be needed in these cases. 
Femtosecond lasers might do a better job of creating predictable, reproducible, round capsulotomies, but there are missed laser spots, causing a postage stamp-like edge, and there are questions as to how this could relate to anterior capsule tears. 
But “smoothness does not necessarily equate to strength,” Dr. Fram said. Studies and company research have found that higher energy leads to more friability. Thus, 4 mJ is the recommended capsulotomy setting, with a horizontal spot size of 5 µm and a vertical spot size of 15 µm to reduce anterior capsule tags.
Dr. Fram finds OCT imaging useful in these cases because it can help predict what could happen in the OR. One of the things that concerns her about the use of femto in capsulotomy creation is the loss of a capsular stress sign that occurs while making a manual capsulotomy. She has been looking for another sign and considers it to be ovalization of the capsulotomy in FLACS cases. 

Editors’ note: Dr. Fram has financial interests with Alcon, Johnson & Johnson Vision (Santa Ana, California), and Bausch + Lomb (Bridgewater, New Jersey).

Cataract surgery in glaucoma patients

Nathan Radcliffe, MD, New York, spoke about considerations for cataract surgery in patients with glaucoma. 
Dr. Radcliffe said that a successful cataract surgery can put glaucoma patients on the path toward their disease stabilizing, while anything other than that can put them in a lot of trouble. This path to success starts with the preoperative evaluation. 
Almost all patients with glaucoma on prostaglandins have meibomian gland dysfunction causing dry eye, which can impact refractive targets and patient satisfaction, Dr. Radcliffe said. He also noted the importance of conducting a preop visual field test with foveal sensitivity turned on to help assess if the patient’s poor vision is due to the cataract or to reduced foveal sensitivity as a result of glaucoma. 
Other considerations in these patients include the iris being more prone to poor dilation and possibility of floppy iris syndrome; vitreous being present after previous glaucoma surgery; and the nerve might be susceptible to IOP elevations. To the latter point, Dr. Radcliffe said three doses of acetazolamide within the first 24 hours after cataract surgery in patients with severe glaucoma is the “single thing most likely to preserve vision in this tumultuous time.” 
Dr. Radcliffe also cautioned that refractive targets can be harder to hit in these patients due to extreme axial lengths, IOL instability, abnormal effective lens position due to anterior segment anatomy or pseudoexfoliation, and possible axial length change from IOP reduction. 

Editors’ note: Dr. Radcliffe has financial interests with Alcon and Glaukos (San Clemente, California).

The Alan Crandall Lecture

Garry Condon, MD, Sarasota, Florida, presented the Alan Crandall Lecture on “Pseudoexfoliation: Evolving IOL Fixation.” 
This systemic condition that always presents bilaterally has a neuropeptide now under investigation to potentially treat the underlying cause of the disease. Pseudoexfoliation glaucoma sees damage that progresses more rapidly, is more severe at the time of diagnosis, and has more frequent need for surgery compared to primary open angle glaucoma, Dr. Condon said. It is more resistant to medication and has been excluded from all of the MIGS trials, but cataract surgery lowers IOP in these patients. 
However, there is a higher risk for intraoperative challenges (poor pupil dilation and zonular laxity) and postoperative complications (IOL/bag complex dislocation). Iris hooks in cataract surgery had their limitations because they dislodged and didn’t support the bag, Dr. Condon said. Capsule retractors with a longer loop design along with the Malyugin ring now allow for more controlled cataract surgery in pseudoexfoliation patients. 
Dr. Condon said Ahmed segments provide the ultimate equatorial bag and zonular support, but there was a time when they were not available in the U.S.
Another challenge with these cases is cortical cleanup. Instead of pulling radially, Dr. Condon described the development of a tangential, banana peel-type approach that puts less stress on the zonules. 
He discussed management of late in-the-bag dislocation. His preference is to keep the existing IOL and fix the IOL/bag complex.
Iris fixation and in-the-bag ab externo scleral fixation are both options. For the latter, Dr. Condon described using 16-mm long curved needles and 9.0 polypropylene to go through the sclera, pushing out the cornea, as a “simple, retrievable suture idea.” This, he said, is his “go-to approach” for a dislocated single piece lens in the capsular bag.

Editors’ note: Dr. Condon has no financial interests related to his comments.

Consent in refractive cataract surgery

Tal Raviv, MD, New York, discussed consent in refractive cataract surgery. He highlighted safe harbor for billing premium cataract surgery and patient education/informed consent. 
Safe harbor with refractive cataract billing means that additional services must be for refractive surgery performed in addition to traditional cataract surgery, and specifically for the treatment of astigmatism and/or presbyopia.
Services that qualify under this safe harbor include limbal relaxing incisions (LRIs) that are manual or femtosecond laser created, toric IOLs, and presbyopia IOLs. However, he noted that some services that do not qualify include ORA (Alcon) by itself, femtosecond laser for a monofocal IOL without LRIs, and use of technologies like Callisto (Carl Zeiss Meditec, Jena, Germany), Verion (Alcon), or TrueVision (Santa Barbara, California) for monofocal IOLs without the treatment of astigmatism.
Dr. Raviv also highlighted the importance of having refractive packages for astigmatism or presbyopia. These can include additional preoperative diagnostic testing, intraoperative services, and additional postoperative services. 
Dr. Raviv went on to discuss patient education and informed consent. He tells patients the goal is to minimize, not eliminate, spectacle use, and he talks to them about nighttime visual phenomenon and quality, as well as the need for additional procedures. 
Dr. Raviv said that with nighttime visual phenomenon, it’s important to explain halos and starbursts to the patient. In addition, there may be a need for additional procedures like laser vision correction, an IOL exchange, or toric IOL rotation.

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

Legislative and regulatory update

Nancey McCann, ASCRS director of government relations, Fairfax, Virginia, shared some of the key MIPS changes for 2019. The 2019 MIPS performance threshold is 30 points, which increased from 15 points in 2018. Physicians and practices must score at least 30 total points to avoid a 7% penalty in 2021. 
The cost category will count for 15% of a physician’s final MIPS score in 2019, which is up from 10% in 2018. Additionally, the category now includes several episode-based cost measures, including one for cataract surgery. For 2019, five Medicare Part B drugs are included, with one pass-through drug. These will be updated on a yearly basis. ASCRS is addressing the pass-through issue directly with the contractor and CMS. Including pass-through drugs in the cost episode defeats the purpose of pass-through. Physicians and groups do not need to submit any data for this category, Ms. McCann said, because CMS will calculate the score based on administrative claims.
In the promoting interoperability category, there were also some changes, namely streamlining and simplification of the requirements and scoring. Participants must report on a single set of required measures, measures requiring patient action have been removed, and health information exchange measures have been modified. Additionally, all participants must use only 2015 edition certified EHR technology in 2019.
She discussed the low-volume threshold. CMS maintained the threshold of $90,000 in allowed Part B charges or 200 patients and added 200 or fewer Medicare professional services. Physicians who exceed one or two but not all three criteria may opt into MIPS for 2019. Practices in areas with high participation in Medicare Advantage may be excluded from MIPS. 
Finally, Ms. McCann highlighted key changes in quality reporting, noting quality reporting via Medicare Part B claims is no longer an option for large practices of 16 or more Medicare-eligible clinicians. Small practices of 15 or fewer may now report as a group through claims but must submit the other categories of MIPS as a group for CMS to score claims data collectively. 

Editors’ note: Ms. McCann has no related financial interests.

Yamane ‘bloopers’

Though the sutureless, double-needle, flanged IOL fixation technique pioneered by Shin Yamane, MD, PhD, has become increasingly popular in the last few years, it is not without its nuances and complications. 
Nicole Fram, MD, Los Angeles, presented several Yamane “bloopers.” One video she showed was pulling too small of a flange back into the sclera. If this happens, you can retrieve it with a 30-gauge needle, but she emphasized that a bigger flange leads to safer surgery. 
Another case was refixation after pupillary capture. In this case, the original surgeon was too anterior and asymmetric in their tunnel length. Dr. Fram exposed and cut the original flange on the side that was overlapping the iris and said cutting the flange on a bevel makes it easier to redock. She brought the haptic back into the anterior chamber, repositioned the IOL, and proceeded with the Yamane technique. 
Dr. Fram also highlighted in a surgical video the importance of making sure your cautery is not near the patient’s eyelid because it’s not comfortable for the patient if you accidentally hit the eyelid. 
Yamane-fixated lenses, Dr. Fram said, are subject to tilt, pupillary capture, and CME. Thus, she said it is important to counsel patients that they might need to be on a nonsteroidal or there might be other issues that need to be addressed. One way she has reduced tilt in these cases is by using a modified marking system. It’s important to be 180 degrees apart but you also need to have a 20-degree angle and 5-degree entry. Dr. Fram reminds herself to make the 20-degree angle by marking 180 degrees apart, then she goes over 2 mm and marks and goes down by 2.5 mm and marks.
Editors’ note: Dr. Fram has no financial interests related to her comments.  

EyeWorld/ASCRS reports from the 2019 Surgical Summit EyeWorld/ASCRS reports from the 2019 Surgical Summit
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