December 2019

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Highlights from the 2019 AAO Annual Meeting in San Francisco


EYEWORLD
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SAN FRANCISCO
OCTOBER 11–15, 2019

Elizabeth Yeu, MD, Norfolk, Virginia, offered pearls for handling white cataracts:
1. Understand your opponent.
2. Decompress the nucleus before
capsulorhexis.
3. Opening the anterior capsule may be the most difficult step.
4. Nuclear densities of white cataracts differ from eye to eye.
5. Vigilantly protect the posterior capsule.

Kevin Miller, MD, Los Angeles, shared general observations from his experience working with artificial irises during his Charles D. Kelman Lecture. The color match is not always perfect, he said, and the iris does not always center in the eye, especially if it is suture fixated. The pupils of the two eyes will not match under all lighting conditions. Additionally, many of these eyes will require subsequent strabismus surgery. Some may also require penetrating or endothelial keratoplasty, and most will require blepharoptosis repair. Glaucoma will continue to be a problem for eyes that had it preoperatively. But, on a positive note, Dr. Miller said the view of the retina and optic nerve through the artificial pupil is excellent.

Yuri McKee, MD, Mesa, Arizona, presented on IOL calculations, and his “biggest piece of advice is to use an IOL calculation from this century.” He recommended the Hill-RBF and Barrett Universal II—which he said have the best refractive results for nearly all eyes—the Barrett True K for post-refractive eyes, and Barrett Toric (used with integrated K).

Eric Donnenfeld, MD, Rockville Centre, New York, said femtosecond arcuate incisions are good for 1 D or less of cylinder. “What I want to create is a femtosecond arcuate incision that opens with a little difficulty,” he said, explaining that he will open one on the table and wait a week before opening the other.

Nicole Fram, MD, Los Angeles, described management of positive and negative dysphotopsias. Positive dysphotopsias, Dr. Fram said, consist of light, streaks/arcs, flashes, and starbursts, while negative dysphotopsias are temporal dark shadows. Positive dysphotopsias can be treated with pharmacological agents (brimonidine 0.15% or pilocarpine 0.5%) or removal and replacement with a different IOL material. Negative dysphotopsias, if they don’t resolve over time, can be managed with reverse (anterior) optic capture or a sulcus-placed IOL. A piggyback IOL or nasal capsulectomy could be considered, she said. 

Clara Chan, MD, Toronto, Canada, discussed management of ocular cicatricial diseases, stressing the importance of staged management.
Step 1: Get any glaucoma optimized. This involves early placement of a tube shunt. 
Step 2: Correct lid abnormalities. If uncorrected, there is poor prognosis for any reconstruction efforts.
Step 3: Suppress inflammation and autoimmune responses, topically or systemically (can also take months to years).
Step 4: Do a trial scleral contact lens. Dr. Chan said this has “revolutionized” how she’s managed these patients. The PROSE device (BostonSight) or impression molded EyePrintPro (EyePrint Prosthetics) can be used.
Step 5: Ocular surface stem cell transplant. Replace conjunctiva or stem cells. Fornix reformation is important because patients can then wear protective contact lenses.
Step 6: Optical cornea transplant. Continue ongoing surveillance for glaucoma, infection, corneal melt, retinal detachment, sterile vitritis, endophthalmitis, etc.
Things to have in your “ocular surface optimization tool box” are lubricants, anti-inflammatories, nutritional support, lid margin disease management, and adjuncts, Dr. Chan said.

Constance Okeke, MD, Norfolk, Virginia, offered several pearls for cataract surgery in eyes with preexisting tubes or trabs. Give preop evaluations more time and thought, and address patient expectations early. MIGS could minimize IOP spike risk, and treat inflammation aggressively. Surgeons need to be prepared for the potential to reposition themselves and incisions depending on bleb positioning. Tubes should be assessed and managed during the procedure if too long or anterior, Dr. Okeke said.

During a keynote lecture on IOL power calculations, Douglas Koch, MD, Houston, sought to answer the question “can we do better?” In the literature, 70–80% of outcomes are within 0.5 D of target, Dr. Koch said, noting that the best data uses the Hill-RBF formula, resulting in 90% within 0.5 D. 
Sources of residual refractive error today are effective lens position (ELP) and the anterior and posterior cornea. 
Dr. Koch said that it’s time to talk about IOL calculation formulas based on how they work instead of generations­—geometric optics, ray tracing, artificial intelligence, and combination formulas. Ideally, ray tracing formulas would be the most accurate, because they incorporate all aberrations of the cornea and the IOL, but a major limitation is that they don’t solve the ELP quandary.
Corneal power also continues to be a major source of error and thus must be optimized. Other best practices for improving IOL calculation accuracy, according to Dr. Koch, include using accurate devices (optical or swept-source biometry and multizone LEDs for K readings), using the best formulas, and verifying quality of raw data used in calculations.

Highlights from EyeWorldTV at AAO 2019


Kevin Miller, MD, discusses a new implant for the treatment of iris defects.


Nicole Fram, MD, discusses pearls for pre-, peri-, and postoperative management for toric IOL cases.

Subscribe at EYEWORLDTV.COM


Deepinder Dhaliwal, MD, discusses treatment strategies for high regular and irregular astigmatism.


Davinder Grover, MD, discusses existing and pipeline micro shunts.

Highlights from the 2019 AAO Annual Meeting in San Francisco Highlights from the 2019 AAO Annual Meeting in San Francisco
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