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EW SHOW DAILY 46 ASCRS Symposia Tuesday, May 9, 2017 by Lauren Lipuma EyeWorld Contributing Writer said. This allows the drug to be absorbed slowly so that it can be active for much longer time periods. However, patients will still need an NSAID drop when using the transzonular approach, Dr. Matos- sian said. Drs. Mah and Matossian agreed that surgeons should never use van- comycin for intraocular injections because it is associated with hem- orrhagic occlusive retinal vasculitis. Dr. Matossian added that surgeons should avoid unbranded, preserved moxifloxacin because of the danger of toxic anterior segment syndrome. But the doctors agreed further research is needed on the transzonu- lar approach, both in its efficacy and its effects on the zonules and the vitreous. Because both drug delivery methods are off label, the ASCRS Clinical Research Committee has started an initiative to develop stud- ies that will allow a perioperative in- jection to be approved, Dr. Mamalis said. This is a huge endeavor because it will require tens of thousands or hundreds of thousands of patients to get a statistically significant result, but Dr. Mamalis is confident it's the right approach. EW Editors' note: The physicians have no financial interests related to their comments. M onday afternoon's Journal of Cataract & Refractive Surgery symposium focused on controversies in anteri- or segment surgery. Edward Man- che, MD, Palo Alto, California, and Roberto Bellucci, MD, Verona, Italy, kicked off the discussion by debat- ing whether corneal procedures or IOL-based procedures are better for managing residual refractive errors after cataract surgery. Performing laser vision correc- tion (LVC) in pseudophakic patients is inherently different than perform- ing a primary LVC procedure for sev- eral reasons, Dr. Manche said. First, pseudophakic patients are going to be older than primary LVC patients by 3 to 4 decades and they may have changes to their tear film or macula that could make the procedure less effective, he said. Next, they may have comor- bidities such as glaucoma that limit their postop visual potential. Often, the visual potential in these patients is going to be less than 20/20, so if you're considering a corneal proce- dure, make sure to set the patient's expectations with what is physically possible, he said. Even with these caveats, studies show LASIK and PRK are effective and predictable when correcting re- sidual myopia in patients with both monofocal and multifocal lenses, Dr. Manche said. When compared to an IOL approach—whether it's IOL exchange or a piggyback IOL— LASIK has been shown to have the advantage. Studies show LASIK offers patients better astigmatism outcomes and can get patients to 20/20 vision more often than IOL methods, he said. Dr. Manche admitted that IOL approaches are better for high degrees of post-surgery refractive error, but thinks corneal approach- es are better for all other cases. Dr. Bellucci, on the other hand, argued that IOL-based procedures offer the advantage of not disrupting the ocular surface, can directly correct the original mistake, and cost less in some countries. Piggyback IOLs may especially be indicated for children, PK eyes, and patients with toric lens- es or high astigmatism, he said. One drawback of piggyback IOLs is that they must be designed for the sulcus, which leaves doctors with fewer options, said session moderator Nick Mamalis, MD, Salt Lake City. Fewer sulcus-based IOLs are approved for use in the U.S., so American doctors have fewer options than doctors in other coun- tries, Dr. Mamalis said. Francis Mah, MD, La Jolla, California, and Cynthia Matos- sian, MD, Pennington, New Jersey, switched up the discussion to the use of intraocular antibiotics during surgery. Dr. Mah argued that in- jecting antibiotics into the anterior chamber is a better method than the transzonular approach used by some physicians to inject antibiotics into the vitreous. One of the advantages to an intracameral injection is that it's a technique anterior segment surgeons already know how to do, Dr. Mah said. In addition, we already know a lot about post-surgical endoph- thalmitis rates with intracameral antibiotics, Dr. Mah said. Studies going back to 2001 have shown intracamerals to be more effective at preventing endophthalmitis than topical drops. However, some con- cerns remain, such as compounding issues and the need for new technol- ogy, he said. On the other hand, we know almost nothing about transzonular antibiotic prophylaxis, Dr. Mah con- tinued. Only two research papers de- scribe outcomes with the transzonu- lar approach in cataract patients, and those two papers cover less than 2,000 eyes, he said. The literature on the intracameral approach covers more than 700,000 eyes, he said. The transzonular approach is also an unfamiliar technique to cataract surgeons and one that has a learning curve, Dr. Mah said. Patients often have vision blur and floaters for several days after the injection, he added. Injecting into the vitreous with the transzonular approach, however, has a depot effect, Dr. Matossian Evaluating controversies in cataract surgery with the femto laser spoke against it, and although good for astigmatic corrections, FLACS had no place in his practice. Diving into the complicated and morphing world of ophthalmol- ogy business, Jeffrey Liegner, MD, Sparta, New Jersey, explained "par," "non-par," and "terminated" Medi- care enrollment options. He pointed out that non-par enrollment meant a physician is still in the network but collects payment directly from the patient. The physician is still obligated to regulations and pun- ishable for misbehavior. Terminat- ing medical enrollment means no longer being subject to any report- ings, he said. Eighty-eight percent of attendees accepted Medicare, private insurances, and MACRA/ MIPS, according to an EyeConnect audience poll. Jane Hughes, MD, San Antonio, encouraged physicians to begin their Medicare exit strate- gies. According to Dr. Hughes, who opted out of the network, her time lost with insurances did not increase practice cost effectiveness. She said communication with patients is key, and although she lost some patients at first, she gained others. After com- ing up with a feasible cash-pay fee schedule, Dr. Hughes found she was a better steward of her cash dollars and her patients as well. Brock Bakewell, MD, Tucson, Arizona, who co-moderated the session, assured ophthalmologists that with all the talk of change, reductions, and restrictions in the air, ASCRS is doing everything it can to support ophthalmology in decreasing the regulatory burden, "fee for service" and free market, a patient's right to choose a doctor of his choice, and preserving the sanc- tity of the doctor/patient relation- ship. He noted that ophthalmology was well-positioned to get bonus money within the MACRA system. Dr. Bakewell invited the attendees to get involved and join the ASCRS grassroots advocacy program and to email regulatory agencies and their representatives in Congress, when asked. According to Sumit "Sam" Garg, MD, Irvine, California, rep - resenting the Young Eye Surgeons (YES) Clinical Committee, the Eye- Connect online forum was voted a great resource to increase awareness among young physicians. Thanks to specific subject threads and the opportunity for physicians to relate real life experiences and opinions, young physicians are able to gain a better understanding of topics they may not get in their home institu- tions. EW Editors' note: Drs. Bakewell, Chang, Garg, Hughes, and Liegner have no financial interests related to their comments. Dr. Rosenthal has financial interests related to his comments. EyeConnect continued from page 44

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