March 2020

ON SITE

Highlights from ASCRS Winter Break
Park City, Utah, Jan. 30–Feb. 1, 2020



Sumit “Sam” Garg, MD

Manjool Shah, MD

James Davison, MD

Douglas Koch, MD

 

Elizabeth Yeu, MD, Norfolk, Virginia, discussed the evolving approach to astigmatism management, providing a number of pearls.
Pearl 1: Identify real vs. false causes of corneal astigmatism.
Pearl 2: Confirm quality using Placido disc topography; confirm quantity (axis, amount) with at least two devices.
Pearl 3: Remember refractive astigmatism is more than what is in the anterior cornea.
Pearl 4: Take advantage of advanced online toric calculators and toric IOL formulas.
Pearl 5: When available, choose a toric IOL over LRI/AK to correct for corneal astigmatism.

Sumit “Sam” Garg, MD, Irvine, California, shared pearls about intraoperative floppy iris syndrome (IFIS).
Pearl 1: Ask the right questions. You want to know if your patient is at risk for IFIS, so go through the chart and ensure they’re not on certain medications. Tamsulosin and alpha blockers can be associated with IFIS.
Pearl 2: Be prepared. When you go into these cases, have the things you think you might need in the room and available to you. Dr. Garg likes to do a “squirt test” to see if the “iris is jumping a little bit.” He also recommended iris expanders.
Pearl 3: Incision management. Dr. Garg recommended anterior incisions, a longer incision, and a low threshold to suture.
Pearl 4: It’s not just for men. IFIS may occur in females as well, Dr. Garg said. Alpha blockers are used for benign prostatic hyperplasia, but they are also used for urinary retention in women, and they’re commonly used for kidney stone management.
Pearl 5: Pressure management. You want to make sure the pressure is equalized, Dr. Garg said, mentioning gradient, hydrodissection, and low-flow phaco. He said it’s also important to come off the infusion before coming out of the eye.

Nathan Radcliffe, MD, New York, New York, presented pearls related to MIGS.
• Use trypan for visualization. This can be used to stain the trabecular meshwork as well as the capsule.
• “New stents on the block.” Dr. Radcliffe mentioned both the iStent inject (Glaukos) and the Hydrus Microstent (Ivantis) as good options.
• There’s room in every practice for both stent and non-stent options.
Dr. Radcliffe also mentioned endoscopic cyclophotocoagulation (ECP) for combo procedures and the XEN Gel Stent (Allergan) ab externo.

Pearls for the Hydrus Microstent from Manjool Shah, MD, Ann Arbor, Michigan, include:
• Use a separate incision. It’s helpful to be 4 clock hours away from the intended entry.
• A small paracentesis helps you maintain the chamber and allows you to rotate the eye a bit.
• Know your anatomy. A long, rigid, misaligned stent can be trouble.
• Engage the canal at an upward angle and flatten out as the stent is deployed. This helps prevent posterior dives.

James Davison, MD, Marshalltown, Iowa, delivered the Crandall Lecture, sharing some of the history of phaco and IOLs. Both were new technologies when Dr. Davison first got into ophthalmology. He called them an “actual paradigm shift,” noting that many people were against them.
At this time, there was a big bang, explosive pace of ideas, with symbiotic contributions by surgeons and industry R&D, he said.
Dr. Davison discussed the history of
IOL development, beginning with Sir Harold Ridley, MD, and the history of phaco, noting
its invention by Charles Kelman, MD. Dr. Davison mentioned a number of surgeons in the field who he worked with and those who made advancements in lenses and techniques. He noted some of his own contributions, including a variation to make different size lenses (either shorter or longer).
In his lecture, Dr. Davison called ophthalmologists “some of the luckiest people in
the world.”

Phaco hacks from Robert Cionni, MD, Salt Lake City, Utah, include:
• Dr. Cionni only hydrodissects one small area, and that’s usually all you need. If one wave doesn’t do it, Dr. Cionni will decompress and put in more fluid and decompress again.
• Dr. Cionni likes pre-chop because everything is already broken up, and you haven’t used any fluid or energy.
• Dr. Cionni uses a one-handed technique. He doesn’t recommend a second instrument unless you need it, finding it creates only one area for fluid egress, better stability, and a more efficient procedure.
• Dr. Cionni generally doesn’t have to move the tip much. If things are coming to it, there’s no need to do manipulation.
• Dr. Cionni suggested that if you have trouble with tremors during surgery, use your second hand to put the index finger right at the incision.

Douglas Koch, MD, Houston, Texas, discussed how to manage rotated toric IOLs. He noted three causes of residual ametropia: misalignment of the IOL with correct spherical power and toricity, inaccurate IOL toric power, and inaccurate IOL spherical power.
Options to address these issues can be IOL based (rotation, exchange, or piggyback IOL) or cornea based (relaxing incisions, excimer laser ablation, or SMILE).
If the spherical power is off, Dr. Koch said the excimer laser can be used, especially if it’s a small correction. He will use this with up to 1.5 D of myopia or up to 1 D of hyperopia.
For larger residual error, Dr. Koch said an IOL exchange may work better, but he noted that this may not be covered by insurance. The patient may insist on this if they think they have the wrong lens in their eye.
Dr. Koch said he likes to use relaxing incisions when patients have a small amount of residual astigmatism.

Nicole Fram, MD, Los Angeles, California, offered her top five pearls for neurotrophic keratitis:
1. Determine etiology. Take a thorough history.
2. Look at the medications. Dr. Fram recommended changing topical medications to preservative free.
3. Use amniotic membrane early in refractory disease.
4. Evaluate and treat abnormal eyelid anatomy and disease.
5. Know when a tarsorrhaphy is necessary and act quickly to avoid corneal thinning.

Editors’ note: Some of the physicians have financial interests with ophthalmic companies.

Park City, Utah, Jan. 30–Feb. 1, 2020 Park City, Utah, Jan. 30–Feb. 1, 2020
Ophthalmology News - EyeWorld Magazine
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