Eyeworld Daily News

EW SHOW DAILY 30 ASCRS Symposia Tuesday, April 17, 2018 which can lead to pigment disper- sion and hyphema and can cause the iris to repeatedly capture the optic. The procedure requires cautery to melt the haptics, so if the haptics get too hot and burn, the reaction can create hydrofluoric acid, which is extremely toxic to the eye. To avoid this, make sure not to touch the cautery to the tip of the haptic and hold it further away when using high temperature cautery, Dr. Safran said. If you're not seeing any burn, it's likely the hydrofluoric acid isn't getting onto the ocular surface, but if you're concerned, flush the eye, he said. New glaucoma technologies Jacob Brubaker, MD, Sacramento, and Michael Greenwood, MD, Far- go, North Dakota, described several new microinvasive glaucoma surgery (MIGS) options for cataract sur- geons. Ophthalmologists are seeing a renaissance of glaucoma care with a range of new technologies that are both safe and effective, Dr. Brubaker said. Dr. Brubaker described how the XEN Gel Stent (Allergan, Dublin, Ire- land) works. The stent is essentially an ab interno trabeculectomy with a much safer profile, he said. The stent is implanted into the subconjunc- tival space and forms a bleb. It is made of a soft, compressible porcine gelatin crosslinked with glutaralde- hyde. The lumen of the stent's tube prevents intraocular pressure from dropping below 8 mm Hg. The key to the implant pro- cedure is placement and making sure it's subconjunctival, not in the stroma, Dr. Brubaker said. The ideal patient for the XEN has an open angle, an untouched conjunctiva, and a target IOP in the mid-teens, he said. The Kahook Dual Blade (KDB, New World Medical, Rancho Cu- camonga, California) is essentially a two-bladed pen that cleanly re- moves trabecular meshwork with- out damaging collateral tissues, Dr. Greenwood explained. The KDB can be used as a standalone procedure or combined with cataract surgery. The dual blade consists of a pointed tip that pierces the trabecu- lar meshwork, a ramp that elevates and stretches the pierced tissue, and a second blade that excises it. The KDB also has a foot plate or heel that prevents damage to the anterior wall of the canal. The ramp is critical to the de- vice's design; stretching the trabecu- lar meshwork over the ramp allows for a precise cut, Dr. Greenwood said. As the blade moves forward, it elevates the meshwork and cuts it above the plane where the tissue usually rests. The KDB requires no addition- al equipment and uses an existing reimbursement code for goniotomy, he added. It offers patients sustained IOP lowering and reduction in med- ications up to 12 months after the procedure, he said. The ideal patient for the KDB is infinite: Surgeons can use it on anyone with mild to end-stage glaucoma, Dr. Greenwood said. It is indicated for all types of glaucoma, including open angle, pigmentary, pseudoexfoliation, and normal tension. It's good for phakic and pseudophakic patients and can be combined with cataract surgery or other glaucoma procedures. The CyPass Micro-Stent (Alcon, Fort Worth, Texas) is another safe and effective MIGS option that de- creases a patient's glaucoma medical burden, Dr. Greenwood said. It's the first MIGS device designed for the supraciliary space and is indicated for use in conjunction with cata- ract surgery for patients with mild to moderate primary open angle glaucoma. The stent is optimized to enhance outflow to the supraciliary space. Inserting it is like sliding a pencil in between pages of a book, he said. The device has four collars, and you should bury two but leave two exposed, he said. EW Editors' note: Dr. Brubaker has finan- cial interests with Allergan. Dr. Green- wood has financial interests with Alcon and New World Medical. Dr. Safran has no financial interests related to his comments. Fundamentals continued from page 29 by Lauren Lipuma EyeWorld Contributing Writer N ew technologies for refractive surgery have recently made their way into the U.S. Military, and the armed forces are now evaluating how well those technolo- gies are doing. In Monday morning's Military Refractive Surgery sympo- sium, physicians gave attendees up- dates on outcomes with procedures like crosslinking, corneal inlays, and SMILE in military personnel. Speak- ers also discussed the prevalence of presbyopia in the military and long- term outcomes of refractive surgery in the armed forces, among other topics. Lieutenant Colonel Scott McClellan, MD, Bethesda, Mary- land, presented lessons learned from the first year of performing corneal crosslinking in the military. Military physicians first per- formed crosslinking in November 2016, after the procedure was approved by the FDA earlier that year. Since then, the military has Military evaluating use of new refractive technologies treated 168 eyes with crosslinking for keratoconus or post-refractive ec- tasia. Almost all patients have been treated using the standard Dresden epithelium-off protocol. Military physicians have learned several lessons from these first 168 eyes. Thin corneas do not respond as well to crosslinking and may be more at risk for developing postop- erative haze, Dr. McClellan said. He said doctors need to educate patients about decreased visual function when the second eye, usually the better-seeing eye, is crosslinked. He also recommends delaying crosslink- ing of the second eye until the first eye can be fitted with glasses or a contact lens for functional vision—a delay of about 3 months. Overall, he has found the pro- cedure to be lengthy and time-con- suming for surgeons and technicians on the day of surgery. Dr. McClellan considers it an expensive procedure in terms of money and manpower Dr. Rivers discusses how implementation of SMILE in the Department of Defense could increase the U.S. Armed Forces' combat readiness. continued on page 32

• Cover