EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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150 EW MEETING REPORTER Reporting live from ASCRS•ASOA Winter Update 2013, Aventura, Fla. March 2013 something a little more involved if they have risk for severe vision loss, but not for those that have low risk of functional visual loss." He discussed minimally invasive glaucoma surgery (MIGS), which offers new options for more moderate glaucoma cases that are less invasive and do not have issues related to compliance. He said performing a trabeculectomy at the time of cataract surgery on stable, early to moderate glaucoma patients to take them off medications, often done during the 1990s, has been steadily decreasing in recent years. "Trabeculectomy, in my opinion, has too much risk, and there are too many safer options for patients with early to moderate disease," he said. However, he still performs filtrating surgery and tubes on patients with advanced glaucoma. He said transscleral surgery is not going away, so safer options for more progressed cases are needed. "Glaucoma management is a chess match—what's your next move and when are you going to make that move. The things that determine that are level of pressure, the more extreme, the more likely [it is] I might do [a more invasive procedure]. If the pressure's 50 [mm Hg], I'm not sure I'm doing MIGS or cataract alone. Their system is so messed up, they need a new outflow system," he said. Editors' note: Dr. Samuelson has financial interests with Alcon. Pearls for patients with diabetic macular edema Editors' note: This Meeting Reporter contains original reporting by the EyeWorld news team from ASCRS•ASOA Winter Update 2013. Keith Warren, M.D., Overland Park, Kan., shared his clinical pearls pertaining to diabetic macular edema (DME) patients in a retina session. "First, I think the important thing to do is perform an assessment of the architectural and circulatory status of the retina," he said. To do this, Dr. Warren suggested that OCT could be an important tool because it helps to better understand the architecture of the retina and tracks how patients are responding to treatment. "OCT allows us in a serial manner to follow changes in the retina and look at the edema as it is Attendees listen intently at a Winter Update session. clearing and how the patient is responding to the therapy that we are instituting," Dr. Warren said. He also said angiography is key to being able to assess the circulatory status of the retina. His next two pearls were to treat patients as though they are at a high risk for postoperative cystoid macular edema (CME) and to manage active DME prior to phaco surgery. The patients should be quiet before surgery, he said, and know that there is an inflammatory component to DME. "Depending on their angiographic changes, it may be that focal laser could be an option for these patients," he said. He also added that anti-VEGF therapy is potent and effective in reducing long-term inflammation in diabetic eyes. Dr. Warren suggested physicians consider the pulse of potent corticosteroid therapy in this patient population. He said this could be with a topical or intracameral steroid. Finally, he said it's important to have careful and regular follow-up. Long-term likelihood of patients' DME can be determined with follow-up of their retinopathy and management of their systemic disease. Editors' note: Dr. Warren has financial interests with Alcon, Dutch Ophthalmic (Exeter, N.H.), and Genentech (San Francisco). Handling phaco in eyes with Fuchs' dystrophy On the topic of phaco in eyes with Fuchs' dystrophy, Edward Holland, M.D., Cincinnati, offered his pearls. First, Dr. Holland said to "develop a grading scale for the severity of Fuchs.'" This is important because it helps a doctor to have a discussion with the patient. With Fuchs,' the preoperative workup should differ from the usual cataract patient, and it is important to individualize each patient's visual needs and prognosis. You can use dispersive OVD to protect the endothelium. For hydrodissection, Dr. Holland said to make sure that the lens is mobilized and that you're not struggling to loosen the lens. "Change your phaco technique in Fuchs' patients," Dr. Holland said. "Don't do the same operation you do for all your other patients." Phaco power is critical, and he noted the importance of minimizing phaco power for these patients. Use any techniques that you can to help make your case go easier, he said. Finally, Dr. Holland advised to establish a relationship with the corneal specialist if that person is not you. Editors' note: Dr. Holland has financial interests with Alcon. continued on page 152