Eyeworld Daily News

EW SHOW DAILY 10 ASCRS News Saturday, April 14, 2018 by Chiles Aedam R. Samaniego EyeWorld Asia-Pacific Senior Staff Writer a rhexis suitably sized for optic cap- ture. Also plan the right replacement IOL to fix the patient's main prob- lem. Tip 2, initiate reopening of the capsular bag using a 26-gauge LASIK cannula. Tip 3, use bimanual haptic stripping to free up fibrosed haptics. Tip 4, if haptics are severely socked, amputate and remove later. Tip 5, deal with a small or phimotic rhexis by stretching it bimanually. You can also tear it if it is not too fibrotic or use iris hooks on the rhexis margin to stretch and hold it open if it is. Tip 6, if you see significant fibrosis, be prepared for loose zonules. Final- ly, tip 7, if the lens is loose, examine the patient lying flat on their back before going to the OR. EW Editors' note: The physicians have no financial interests related to their comments. T he third session during Refractive Day was a rapid-fire symposium with experts providing their best "Tips, Pearls, and Take- Home Messages." Steve Charles, MD, German- town, Tennessee, kicked off the session with his tip for dealing with cataract surgery surprises. He was referring, he said, to surprises that occur even when you have the refractive measurements "perfectly right" and are due to inadequacies in routine preoperative evaluation. Many critical factors are in- visible to standard evaluation. For instance, macular diseases are seen only on OCT. To that end, he recommended performing OCT imaging on all patients. Spectral OCT in particular, he said, is essential, adding that time-domain OCT is obsolete. The session's speakers then took turns providing their tips in a series of 2-minute talks. Among them, Cathleen McCabe, MD, Sarasota, Florida, described the use of a cannula she specially designed for femto cataract surgery incisions, used to help get into incisions, useful for cutting through fibrotic bridges during IOL exchange. Blake Williamson, MD, Denham Springs, Louisiana, recommended that sur- geons "always look at the topogra- phy before examining the patient in the office for refractive cataract surgery," also demonstrating how he performs superficial keratectomy at the slit lamp to deal with what he called "covert epithelium" from ocular surface disease. In contrast to these clinical tips, Gregory Parkhurst, MD, San Antonio, California, gave his "single biggest tip" on market growth. He recommended that surgeons collab- orate with other surgeons they think are their competition, and that together they should get better at educating their entire market about the benefits of refractive surgery, rather than quarreling over "a tiny sliver of the pie." In particular, he said the refrac- tive surgical community needs to educate their market to have them move from contact lenses to refrac- tive surgery—what Dr. Parkhurst called "the biggest no-brainer." The reality from the historical perspective, he said, is that refractive surgery is still a relatively nascent specialty. Refractive surgery will eventually replace contact lenses, but surgeons must realize this de- pends on the perception of patients. Rather than competing with each other and comparing technol- ogies, comparisons often resulting only in instilling fear in patients, surgeons should simply start per- forming surgery and educating their patients about the benefits of refrac- tive surgery procedures. Meanwhile, the wisest thing Karl Stonecipher, MD, Greensboro, North Carolina, said he could think of in terms of refractive surgery was "refraction refraction refraction … if your information is bad, then your surgery will be bad." To deliver the best outcomes requires having a good measurement of manifest refraction. He thus recommended that surgeons follow the dictum of measuring twice, but cutting only once. Ending the session, Steven Sa- fran, MD, Lawrenceville, New Jersey, provided seven tips for "biting the bullet" and performing an IOL ex- change on the lens you put in, when all else fails. Tip 1, plan ahead when doing your cataract surgery by clean- ing lens epithelial cells and making Refractive tips, pearls, take-home messages Dr. Safran provides his best tips for performing IOL exchange. Over the years, surgeons have been making blebs weaker, favoring pressure lowering over, possibly, safety—10 to 15%, Dr. Shaarawy said, end up with bleb dysesthesia. by efficacy, cost, safety, and the ability to combine with phaco; more recently, glaucoma surgery has been driven by phaco surgeons, who have started taking a more important role in the surgical management of glau- coma, and the patients themselves, who today are more demanding, asking more questions, more savvy over the internet, and will sooner or later dictate choices. As well they should, Dr. Shaarawy said. He suggested sur- geons should thus be more con- cerned with visual preservation, comfort level, learning curve, as well as the ability to combine procedures and cost-effectiveness. EW Editors' note: Dr. Shaarawy has no financial interests related to his comments. Dr. Shaarawy discusses the patient's perspective on glaucoma surgery. Glaucoma surgery, he said, leads to quantitative and qualitative loss of vision, eye comfort, and quality of life. Patients complain that doc- tors don't understand what patients need, and how their vision pertains to real life. Will new options change the game? While the jury is still out on the impact of MIGS in terms of visual outcomes, they do pro- vide faster visual rehab, shortening recovery time from 4 weeks to a few days—a significant difference from any standpoint, but most especially to patients. MIGS procedures take away discomfort from blebs—although Dr. Shaarawy quickly qualified that these procedures can also cause discomfort, and patients should be informed of the possibility. Finally, loss of vision can also occur with MIGS; MIGS, he said, is "not the holy grail of glaucoma procedures." In the past, Dr. Shaarawy said that glaucoma surgery was driven Prioritizing continued from page 6

• Cover