Eyeworld Daily News

continued from page 1 MAY 6, 2019 | EYEWORLD DAILY NEWS | 3 were then narrowed down by the Program Committee. Contes- tants took to the podium at the meeting to share their presen- tations on several controversial issues. Coaches, with their backs to the contestant, only turned if they wanted to vie for being that person's mentor, supporting their stance on the issue. Following, a panel of experts presented coun- terpoints. Dr. Raviv's presentation was about endophthalmitis prophylaxis with intracameral antibiotics. It's a must, Dr. Raviv said. Coaches John Berdahl, MD, Sioux Falls, South Dakota, and Dr. Ahmed immediately turned in support after hearing just the title of the topic and Eric Donnenfeld, MD, Rockville Centre, New York, soon followed. Dr. Raviv presented what he called "overwhelming evidence of efficacy" to support the use of in- tracameral antibiotics. The Kaiser study, he noted, showed a 22-fold reduction of infection over topical antibiotics, and the Aravind study showed a 3.5-fold reduction of endophthalmitis with intracam- eral moxifloxacin. He also cited several studies that showed no additive effect of topical antibiot- ics after intracameral antibiotics were used and noted that a 2016 AAO Preferred Practice Pattern supports the role of intracameral antibiotics. Adoption of intracameral antibiotics among U.S. surgeons, unlike their European counter- parts, however, is low. Dr. Raviv said concern could stem from there not being an FDA-approved product and the association of intracameral vancomycin with HORV. Cefuroxime and moxi- floxacin are alternatives to intra- cameral vancomycin for those concerned about the latter. Dr. Raviv said compounding pharma- cies and the commercially available topical formulation of moxiflox- acin are options for intracameral antibiotics. Dr. Raviv pointed out that ophthalmologists use other drugs in off-label indications quite regularly, as well as compounded formulations of other medica- tions. Dr. Raviv ultimately chose Dr. Ahmed to be his coach. Deepinder Dhaliwal, MD, Pittsburgh, gave the rebuttal, saying that because bacteria live in the lids and lashes, preop antisep- sis with a double povidone iodine prep should be stressed. This is the key to decreasing the rate of endophthalmitis, she said, and none of the studies mentioned by Dr. Raviv had standardized tech- niques of preop antisepsis. This, followed by a postop antibiotic regimen, has led to zero cases of endophthalmitis in her practice. Topical moxifloxacin, Dr. Dhaliwal cautioned, is not 100% effective or benign. Dr. Ahmed said that antisepsis protocols and intracameral antibi- otic use are mutually exclusive. We should do both, he said. Daniel Terveen, MD, a fourth-year resident at the Uni- versity of Iowa, who chose Dr. Berdahl as his coach, presented on immediate sequential bilater- al cataract surgery (ISBCS). He argued that ISBCS is better for the patient, surgeons, and the system. It decreases debilitating anisometropia, reduces the num- ber of patient visits, and reduces time spent off work for both the patient and anyone helping them for appointments. Dr. Terveen also mentioned several studies that support the safety and efficacy of ISBCS compared to standard cataract surgery. Concerns include bilateral infection (TASS, endophthalmitis, HORV) and refractive surprise, but Dr. Terveen said the real rea- son more surgeons in the U.S. are not doing it is likely economical. There is no financial incentive to do ISBCS in the current system. Dr. Dhaliwal retorted that even if incidence of these bilateral infections is extremely rare, based on the data and analysis shown by Dr. Terveen, "if it happens to a patient, it's 100%. Why would you take the risk, even if it's tiny?" Dr. Berdahl, defending his contestant, said the only way you're not going to have a complication is if you do no work. Other topics presented by contestants and supported by coaches included taking a pause with MIGS by Constance Okeke, MD, Norfolk, Virginia, with coach Elizabeth Yeu, MD, Norfolk, Virginia, emphasizing the importance of surgeon to surgeon training; the continued viability of anterior chamber IOLs by Sumi- tra Khandelwal, MD, Houston, with Dr. Donnenfeld; and the use of presbyopia-correcting IOLs in eyes with other comorbidities by John Hovanesian, MD, San Clemente, California, with Dr. Ahmed. Editors' note: Dr. Okeke and Dr. Ho- vanesian have financial interests with a number of ophthalmic companies. Drs. Khandelwal, Yeu, Berdahl, Terveen, Dhaliwal, Ahmed, Donnenfeld, and Raviv have no financial interests related to their comments. Dr. Donnenfeld, Dr. Yeu, and Dr. Berdahl serve as coaches for the second season of The Voice of Ophthalmology.

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