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12 EW SHOW DAILY Tuesday, April 23, 2013 ASCRS Symposia Techniques for the anterior segment surgeon by Erin L. Boyle EyeWorld Senior Staff Writer Theo Seiler, MD T opics ranging from microincision glaucoma surgery (MIGS) to femtosecond laser-assisted cataract surgery to DMEK versus DSAEK to collagen crosslinking technique were debated, compared, and discussed in a symposium Monday. At the "Focus on Technique: What the Anterior Segment Surgeon Needs to Know in 2013" symposium, sponsored by the Journal of Cataract & Refractive Surgery, physi- cians took opposing views or discussed varying aspects of technology techniques, providing pearls and tips along the way. Reay H. Brown, MD, Atlanta, and Steven D. Vold, MD, Fayetteville, Ark., discussed the iStent (Glaukos, Laguna Hills, Calif.) in the "Microincision Glaucoma Devices: Who Should Use Them and When?" segment. Jason J. Jones, MD, Sioux City, Iowa, and William B. Trattler, MD, Miami, presented their opinions on "Femtosecond Laser– Assisted Cataract Surgery: Tales From the Learning Curve." Peter S. Hersh, MD, Teaneck, N.J., and Theo Seiler, MD, Zurich, discussed "Collagen Crosslinking Technique: What Does the Evidence Support and Where Are We Headed?" Drs. Hersh and Seiler gave pearls on lessons that they have learned about crosslinking at the end of their talks. Dr. Hersh said standard crosslinking with epithelium off is similar to PRK in that ocular surface management is vital. "I have a crosslinking patient, I am going to treat them much as I would a pre-PRK patient, treat any blepharitis, treat any dry eye, manage their bandage contact lens afterward in a similar type of fashion. Don't ignore the ocular surface. Maximize re-epithelialization and the quality of the surface afterwards," he said. Dr. Seiler, who published the first papers on crosslinking, said miscounseling is the biggest mistake that can be made with a potential crosslinking patient. "The patient has certain expectations of what is going on, and you have to tell them that it's painful, they will not see very well during Based on what you have learned today, do you believe that low to moderate ocular inflammation can significantly impact visual quality and patient 5% Strongly disagree 1% Disagree 2% Neither agree nor disagree 37% Agree 55% Strongly agree Data taken from the EyeWorld CME Education event "Understanding and Managing the Impact of Cataract Surgery Stress on Ocular Inflammation: Uveitis, CME, and Corneal Edema," which was supported by an unrestricted educational grant from Alcon. the first month, and it will take a year before they really see the benefit of the procedure," he said. "Take your time to counsel your patients." Francis W. Price Jr., MD, Indianapolis, and Mark A. Terry, MD, Portland, Ore., discussed Descemet's membrane endothelial keratoplasty (DMEK) and Descemet's stripping automated endothelial keratoplasty (DSAEK) in the "DMEK Versus DSAEK" segment. After their presentations, they debated whether DMEK or DSAEK had the better visual acuity. Dr. Price said that DMEK is a superior procedure. "We've shown that for our patients, it's probably about one or two lines of improvement. But that's only part of the story," he said. "The other part is that, Snellen acuity is not everything with vision. If it was, we wouldn't do cataracts in people that have a [posterior subcapsular cataracts] and they can read 20/20 on the eye chart. And the same thing with Fuchs' dystrophy, I've been doing a number of people." "In fact I had an unusual case with guttata, limbus to limbus, [in] a 22-year-old," he said. "She had absolutely no edema and can't remember ever seeing well, so I'm not sure what the cause of this is … She's tremendously improved. With the first eye, she said she'd never seen so well in her life and wanted the other eye done. So we underestimate, greatly, the impact of guttata on vision and I think, at least in our practice, we've totally re-thought this whole ratings system, about when you operate and when you don't, because there is a lot of disability that these people have for night driving." He said that in those cases, DMEK will be more effective than DSAEK. EW Editors' note: Dr. Brown has financial interests with Ivantis (Irvine, Calif.) and Transcend (Menlo Park, Calif.). Dr. Vold has financial interests with AqueSys (Aliso Viejo, Calif.), Glaukos, iScience Interventional (Menlo Park, Calif.), Ivantis, NeoMedix (Tustin, Calif.), SOLX (Waltham, Mass.), and Transcend. The other doctors have no financial interests related to this article.