November 2018


EyeWorld/ASCRS reports from the ASCRS Young Eye Surgeons Advanced Cataract Training

EyeWorld/ASCRS reports from the ASCRS Young Eye Surgeons Advanced Cataract Training,
September 15–16,
San Francisco

Astigmatism essentials

Kicking off the first session of the day on astigmatism, Winston Chamberlain, MD, Portland, Oregon, discussed how to accurately identify anterior and posterior corneal astigmatism. He offered several pearls on this topic. 
First, he suggested talking to your patients. This could include asking patients about their specific needs and expectations with cataract surgery, asking them about their favorite activities, asking about difficulties with their current activities and daily living, and asking if they mind wearing glasses.
Next, Dr. Chamberlain said to “talk to yourself.” He said it’s important to consider if a certain IOL choice makes sense for the patient, and he said that he often considers if he would make the same decision for a family member. 
Other important points Dr. Chamberlain highlighted were to do a careful slit lamp exam, not to rely on a single device, look at the anterior curvature, and look at the posterior corneal curvature.
He added that direct measurements will be better than assumptions, and adjustable lenses or exchangeable IOLs may be options in the future. 
Michael Greenwood, MD, Fargo, North Dakota, discussed astigmatic keratotomy, highlighting femtosecond and manual AKs. He first mentioned the statistic that 52.5% of patients with cataracts have more than 0.75 D of clinically significant pre-existing corneal astigmatism. He noted it’s important to make sure the astigmatism is regular, rule out any confounding corneal pathology, and plan treatment based on a nomogram. 
For manual AKs, Dr. Greenwood noted several steps, particularly stressing that it’s important the patient is sitting upright when marking. 
He then highlighted the difference between manual and femto. With femto, it’s the same planning process, Dr. Greenwood said, but the laser does the cutting for you. There is a precise depth and placement, continuous curvature, and the ability to titrate the incision with femto as well. 
He also stressed that femto is photodisruptive, you can’t use the same nomograms (you may get overcorrection if using a manual nomogram with femto), and centration is the most critical step in femto (decentration can be an issue). 
In summary, Dr. Greenwood said that manual LRI and femto AKs are both excellent options for astigmatism correction. Astigmatism management at the time of cataract surgery is an essential component to providing high uncorrected quality of vision, he said, and surgeons striving to achieve refractive outcomes should be comfortable with manual LRIs and femto corneal incisions.

Editors’ note: Dr. Chamberlain has no financial interests related to his presentation. Dr. Greenwood has financial interests with Alcon (Fort Worth, Texas).

Optimizing the ocular surface

A panel during the Saturday morning session covered optimizing the ocular surface. Ashley Brissette, MD, New York, Marjan Farid, MD, Irvine, California, Nicole Fram, MD, Los Angeles, Samuel Lee, MD, Sacramento, California, and Sumit “Sam” Garg, MD, Irvine, discussed the topic.
Dr. Garg stressed the importance of looking at the meibomian glands. You want to push on the glands, he said, and using a Q-tip or finger to push on the glands can help the physician see how easy or hard it is to express meibum and what the quality of the meibum is. 
Dr. Lee said that in his practice, meibomian gland disease management is mostly individualized. He said it’s important to use a variety of tools, to squeeze the lids, and to look at the quality of oil. When making a diagnosis, Dr. Lee said that TBUT, rosacea, the quality of the lids, and quality of eyelashes may all be factors.
Dr. Farid stressed the importance of patient education, particularly noting the number of patients she sees who do not routinely remove their makeup, which can become a problem.

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

Incorporating presbyopia-correcting IOLs into practice

A late morning session on Saturday focused on presbyopia-correcting IOLs. Dr. Lee highlighted some of the patient considerations for advanced technology IOLs. He presented several cases, dissecting certain factors that may or may not make a patient an ideal candidate for this technology. He also offered characteristics of “the ideal candidate”: hyperopic, healthy ocular surface, little to no astigmatism (or regular astigmatism), an easy-going and positive personality, tolerant to using glasses to some degree after surgery, tolerant to some dysphotopsia, and tall with long arms. However, Dr. Lee did note that it’s unlikely you will encounter a completely perfect candidate. He also noted that having the patient fill out a questionnaire, obtaining biometry and topography, performing an exam, and understanding the patient’s expectations and goals are key steps in choosing an IOL option and ultimately having a happy patient.

Editors’ note: Dr. Lee has financial interests with Allergan (Dublin, Ireland).

Maximizing outcomes and managing patient expectations after cataract surgery

Amy Lin, MD, Salt Lake City, shared tips for how to approach the unhappy postoperative patient when the outcome falls short of expectations. You may encounter these patients in cases where you were not the surgeon and the patient wants a second opinion, she said, or when you were the surgeon. 
In cases when you were not the surgeon, Dr. Lin said that one of the most important things is not to blame the surgeon, regardless of your personal views. You can explain that complications are part of the risk of surgery, she said, and explain that people react differently to surgery and heal differently. Asking for the patient’s records is another way to continue helping that patient.
Meanwhile, if you’re dealing with an unhappy postoperative patient when you were the surgeon, Dr. Lin said that preoperative counseling is very important. She said she never guarantees a good result, and it’s important to have proper informed consent. Dr. Lin added that you should disclose any mistake or complications and discuss with the patient that it’s possible that unexpected events can happen, and it’s not necessarily anyone’s fault. 
Dr. Lin said it’s also important to be available to the patient, to be an advocate for the patient, and to be open to a second opinion. She added that you may consider contacting risk management, depending on the case.

Editors’ note: Dr. Lin has no financial interests related to her presentation.

Dry eye breakfast

A breakfast session sponsored by Shire (Lexington, Massachusetts) delved into dry eye. Dr. Fram led a presentation and discussion, highlighting dry eye and Xiidra (lifitegrast, Shire). 
When addressing dry eye with patients, you have to realize there’s a huge amount of the population who doesn’t know they have dry eye, she said, adding that dry eye can present in different ways. 
Dr. Fram said that when she was training, the way to treat dry eye was to prescribe an artificial tear. However, she noted that inflammation is a key component of dry eye disease, and it can cause ocular surface and tissue damage. Inflammation is a continuous cycle that will exacerbate dry eye until it is interrupted, she said. To treat dry eye, Dr. Fram said to consider treating the inflammation. 
She also mentioned several common risk factors that can lead to dry eye: topical and systemic medications, contact lens wear, non-surgical procedures, ophthalmic surgery, comorbid conditions, and digital device use. Symptoms of dry eye disease are variable and can interrupt daily activities.
Dr. Fram went on to discuss Xiidra to treat dry eye. She particularly noted data from five clinical trials with more than 2,400 patients with Xiidra: four 12-week trials and one where patients were followed for a year. In three out of the four 12-week studies, Xiidra showed improvement in inferior corneal staining at 12 weeks. She added that in all four of the 12-week studies, Xiidra showed relief from eye dryness at 6 and 12 weeks. There are some possible adverse reactions, Dr. Fram noted, which could include instillation site irritation, dysgeusia, and reduced visual acuity. The majority of adverse reactions were considered mild to moderate in the 1-year safety study, Dr. Fram said. 

Editors’ note: Dr. Fram has financial interests with Shire.

Managing the complex cataract patient

A video/case-based session on Sunday morning focused on managing the complex cataract patient. Dr. Lin shared a case dealing with iris prolapse. She first highlighted some of the risk factors for iris prolapse: pressure gradient present (too much posterior pressure), wound issues (too short, pushing on posterior lip), IFIS, the pupil not well dilated, and excessive iris manipulation. 
In dealing with iris prolapse, Dr. Lin said that the first rule is to always decompress the anterior chamber. If iris prolapse is mild, place viscoelastic to push it into the anterior chamber, she said. Gently reposit with a cannula (via wound or sweep across from paracentesis) and tap on the wound. 
Dr. Lin then shared a situation where iris prolapse complications occurred in a routine cataract case. Dr. Lin’s 85-year-old patient had a lot of posterior pressure. She began with hydrodissection and saw big gradient coming out. But instead of compressing the anterior chamber, Dr. Lin tried to sweep the iris back, which caused a large iridodialysis. Dr. Lin was losing the iris/pupil margin. She put in iris hooks to try to help stabilize and get the iris back in. Eventually, Dr. Lin was able to get the wound sealed and sweep the iris back in, and her patient ended up happy and the iridodialysis settled down.
Dr. Farid discussed management of pediatric cataracts. These require special considerations, she said, relating to the capsulorhexis, posterior capsulotomy and anterior vitrectomy, wound closure, and IOL options.
When considering the capsulorhexis, Dr. Farid said that the anterior capsule is thicker and elastic in the pediatric population. She suggested physicians “shear instead of tear,” and start smaller, and you can enlarge after IOL placement. 
The posterior capsulotomy considerations depend on the age of the patient. If the patient is able to sit for a YAG, there is no need for a posterior capsulotomy, she said. 
Dr. Farid noted that clear corneal wounds in pediatric eyes don’t seal very well with standard stromal hydration, and you may want to consider if suture closure is feasible in your patient. She said that a scleral tunnel wound may be considered if you’re dealing with a toddler or if there is concern for eye rubbing. 
She also mentioned that all IOL options are considered off-label for the pediatric population. If you’re deciding to use an IOL, which could be a good option if the patient is older than 2 years old, it’s important to discuss with a pediatric ophthalmologist. She added that toric or multifocal/extended depth of focus lenses could be a good option in the adaptable pediatric population. 
Also during the session, Thomas Oetting, MD, Iowa City, Iowa, shared his “5 tips for hyperopes.”
He first noted that the formula is critical. He said that a small pupil is common, and there may be risk of iris prolapse. Because of this, there is less room for a ring, so Dr. Oetting prefers iris hooks in these cases.
He said to beware of laser peripheral iridotomy (LPI), to protect the endothelium, and to break the nucleus into small pieces.

Editors’ note: Drs. Lin and Oetting have no financial interests related to their presentations. Dr. Farid has financial interests with a number of ophthalmic companies.

Innovations in glaucoma surgery

During a Saturday afternoon session focused on glaucoma surgery, Blake Williamson, MD, Baton Rouge, Louisiana, shared his nine pearls for intraoperative gonioscopy. With MIGS, the key is visualization, he said, and you can’t treat what you can’t see. 
First, he highlighted office- based gonioscopy, saying that intraoperative gonioscopy is not a substitute for slit lamp-based gonioscopy. Next, he said to know your angle anatomy. He also highlighted anesthesia use, indicating that topical anesthesia is usually fine. 
Dr. Williamson discussed head/microscope rotation, goniolens selection, hand positioning, the corneal incision, the importance of good OVD fill, and goniolens docking. 
He suggested creating the corneal incision just inside the limbus and noted that he uses cohesive OVD. In terms of goniolens docking, Dr. Williamson said to align the light along the iris plane, not the corneal plane.
Also during the glaucoma session, Kuldev Singh, MD, Palo Alto, California, shared several reasons why he thinks trabeculectomy will survive, despite the MIGS revolution: individualization of surgical goals, postoperative titration possible, proven long-term success, option of inferior drainage tube implant, and the aging population. 
In another presentation, Dr. Williamson shared some important information for cataract surgery in the post-glaucoma surgery patient. He offered preoperative, intraoperative, and postoperative considerations.
Preoperatively, he said to evaluate bleb function, postpone cataract surgery if the patient has had a recent trabeculectomy (wait at least 6 months), use gonioscopy to view internal ostomy of the trabeculectomy, beware of high IOP, assess pupillary dilation, and look for pseudoexfoliation/zonular stability.
Intraoperatively, Dr. Williamson said to try to do as minimal manipulation as possible, avoid retrobulbar anesthesia, make incisions away from the bleb, avoid pupillary miosis, break posterior synechiae and pupillary membrane, use dispersive OVD to protect the endothelium, beware the shallow anterior chamber, remove all cortex to prevent inflammation, don’t break the bag, avoid a multifocal in these end-stage patients, and remove OVD behind the lens.
Finally, Dr. Williamson stressed that some important postoperative considerations are to watch for early IOP spikes, use frequent topical steroids, watch for steroid response, look for early bleb failure, and consider anti-fibrotics.

Editors’ note: Dr. Williamson has financial interests with Glaukos (San Clemente, California). Dr. Singh has financial interests with a number of ophthalmic companies.

Innovations and hot topics in cataract surgery

The final session of Saturday’s afternoon program highlighted a number of hot topics and innovations in cataract surgery. Julie Schallhorn, MD, San Francisco, shared information on uveitic cataracts. She mentioned that intraocular surgery can induce a uveitis flare, and inflammation can be very bad in these cases. It’s important to control inflammation, she said, and you need to have an inflammation plan and a surgical plan. 
Before you operate, Dr. Schallhorn said that the general rule of thumb is that the patient has been quiet for 3 months and you’re able to control flares. She said to keep patients on immunosuppressants during surgery and supplement with additional anti-inflammatories. 
She added that CME prevention is also important because CME is the number one cause of vision loss in uveitis. 
Since “anything can happen” when doing surgery with uveitic cataracts, Dr. Schallhorn said the important things to consider are visualization, the capsulotomy, your lens disassembly technique, and IOL choice.

Editors’ note: Dr. Schallhorn has no financial interests related to her presentation.

EyeWorld/ASCRS reports from the ASCRS Young Eye Surgeons Advanced Cataract Training EyeWorld/ASCRS reports from the ASCRS Young Eye Surgeons Advanced Cataract Training
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