Eyeworld

67 EW INTERNATIONAL August 2018 3. Kelly TL, et al. Repeat penetrating corneal transplantation in patients with keratoconus. Ophthalmology. 2011;118:1538–42. 4. Borderie VM, et al. Long-term results of deep anterior lamellar versus penetrating ker- atoplasty. Ophthalmology. 2012;119:249–55. 5. Coster DJ, et al. A comparison of lamellar and penetrating keratoplasty outcomes: a reg- istry study. Ophthalmology. 2014;121:979–87. 6. Jones MN, et al. Penetrating and deep anterior lamellar keratoplasty for keratoco- nus: a comparison of graft outcomes in the United Kingdom. Invest Ophthalmol Vis Sci. 2009;50:5625–9. 7. Romano V, et al. Long-term outcomes of deep anterior lamellar keratoplasty in patients with keratoconus. Am J Ophthalmol. 2015;159:505–11. 8. Dua HS, et al. Human corneal anatomy redefined: a novel pre-Descemet's layer (Dua's layer) Ophthalmology. 2013;120:1778–85. Editors' note: Dr. Allan has no finan- cial interests related to his comments. Contact information Allan: bruce.allan@ucl.ac.uk thinks that this will not be a prob- lem going forward. "You've heard of precut donors, maybe in the future we will be seeing precut patients, too." EW References 1. Reinhart WJ, et al. Deep anterior lamellar keratoplasty as an alternative to penetrat- ing keratoplasty: a report by the American Academy of Ophthalmology. Ophthalmology. 2011;118:209–18. 2. Kelly TL, et al. Corneal transplantation for keratoconus: a registry study. Arch Ophthal- mol. 2011;129:691–7. and put the button on, with inter- rupted sutures for the best results," Dr. Allan said. "The mini bubble technique respects the pre-DM layer anatomy. It has a nice edge profile with no mismatches. There are reduced perforation rates versus con- ventional DALK, and we are hoping that the 9 mm graft will reduce the risk of late ectasia progression peripheral to the graft, a common problem in conventional transplan- tation for keratoconus." What if the corneal transplant practice is not co-located with a refractive surgery facility? Dr. Allan "Problems in big bubble DALK can be understood with reference to Harminder Dua's work on the anato- my of the pre-Descemet membrane, 8 which inserts into the stroma at about 6–8 millimeters diameter," Dr. Allan said. "We saw that all of our perforations were occurring when we were dissecting in the periph- ery or trying to expand the bubble toward an 8 mm conventional DALK graft margin. With that in mind, we have moved on to another tech- nique, mini bubble femto DALK." Dr. Allan developed this vari- ant of the big bubble technique, in which he uses a femtosecond laser to create a mushroom graft with a 6 mm Descemet's membrane baring optical center and a 9 mm outer diameter. Donor preparation is facili- tated by mounting the cornea over air for laser interface applanation. Air is compressible, and this helps consistent applanation at a firm pressure for clean laser trephination. The reciprocal dissection in the host stroma is taken to within approxi- mately 75 microns of the thinnest point at 6 mm. This helps deep cannula location for successful big bubble formation. "I like to take the endothelium off the donor, clean the interface, " Why is it that our head is telling us to use DALK? Because it avoids the endothelial rejection and accelerated endothelial cell loss that are seen in PK. " —Bruce Allan, MD View the EyeWorld CME and non-CME supplements at: cmesupplements. eyeworld.org supplements. eyeworld.org Innovations in cataract and refractive surgery Updates to the LenSx Laser and WaveLight Refractive Suite improving the user experience The news magazine of the American Society of Cataract & Refractive Surgery digital.eyeworld.org Supplement to EyeWorld Daily News Saturday, April 14, 2018 Featuring: Michael Gordon, MD Terry Kim, MD Cathleen McCabe, MD Mark Lobanoff, MD The physicians are consultants for Alcon and received compensation for their contributions to this supplement. Sponsored by The third refractive surface: Improving surgical outcomes with advanced diagnostics and therapeutics continued on page 2 Accreditation Statement This activity has been planned and imple- mented in accordance with the accreditation requirements and policies of the Accredi- tation Council for Continuing Medical Edu- cation through the joint providership of the American Society of Cataract and Refractive Surgery (ASCRS) and EyeWorld. ASCRS is accredited by the ACCME to provide continu- ing medical education for physicians. Educational Objectives Ophthalmologists who participate in this activity will: • Improve practice protocols for the screening, diagnosis, and classification of ocular surface disease Designation Statement The American Society of Cataract and Refractive Surgery designates this enduring materials educational activity for a maximum of 1.0 AMA PRA Category 1 Credits. ™ Phy- sicians should claim only credit commensu- rate with the extent of their participation in the activity. Claiming Credit To claim credit, participants must visit bit.ly/2vfjjgk to review content and down- load the post-activity test and credit claim. All participants must pass the post-activity test with a score of 75% or higher to earn credit. Alternatively, the post-test form included in this supplement may be faxed to the number indicated for credit to be awarded, and a certificate will be mailed within 2 weeks. When viewing online or downloading the material, standard internet access is required. Adobe Acrobat Reader is needed to view the materials. CME credit is valid through February 28, 2018. CME credit will not be awarded after that date. Notice of Off-Label Use Presentations This activity may include presentations on drugs or devices or uses of drugs or devices that may not have been approved by the Food and Drug Administration (FDA) or have been approved by the FDA for specific uses only. ADA/Special Accommodations ASCRS and EyeWorld fully comply with the legal requirements of the Americans with Disabilities Act (ADA) and the rules and regulations thereof. Any participant in this educational program who requires special accommodations or services should contact Laura Johnson at ljohnson@ascrs.org or 703-591-2220. Financial Interest Disclosures Kenneth Beckman, MD, has an investment interest in and has received a retainer, ad hoc fees or other consulting income from EyeXpress and RPS. He has received a retainer, ad hoc fees or other consulting income from and is a member of the speakers bureau of: Alcon, Allergan, Shire, Sun Pharma, and TearLab. Dr. Beckman has received a retainer, ad hoc fees or other consulting income from Bausch + Lomb and TearLab. Eric Donnenfeld, MD, has an investment interest in and has received a retainer, ad hoc fees or other consulting income from: AcuFocus, AqueSys, Elenza, Glaukos, Icon Biosciences, Kala Pharmaceuticals, Katena, Mimetogen, Novabay, Omeros, PRN, and TearLab. He has an investment interest in: LacriScience, Mati, Omega Ophthal- mics, Ocuhub, Pogotec, RPS, Strathspey Crown, TrueVision, and Versant Ventures. Dr. Donnenfeld has received a retainer, ad hoc fees or other consulting income from: Abbott, Alcon, Allergan, Bausch + Lomb, Beaver-Visitec, Foresight, Novaliq, Shire, and TLC Laser Centers. He is a member of the speakers bureaus of: Pfizer, RPS, and TLC Laser Centers, and he has received research funding from: Alcon, Allergan, Bausch + Lomb, Beaver-Visitec, Icon Biosciences, Kala, Omeros, PRN, and Shire. Francis Mah, MD, has an investment inter- est in Sydnexis. He has received a retainer, ad hoc fees or other consulting income from Abbott, Aerie, Alcon, Allergan, Bausch + Lomb, CoDa, NovaBay, Ocular Science, Okogen, Omeros, PollyActiva, Shire, Sun Pharma, TearLab. Dr. Mah is a member of the speakers bureau of: Abbott, Alcon, Allergan, Bausch + Lomb, Shire, and Sun Pharma. He has received research funding from Abbott, Allergan, and Ocular Science. Christopher Starr, MD, has an investment interest in GlassesOff/Innovision and Tear- Lab. He has received a retainer, ad hoc fees or other consulting income from: Allergan, Bausch + Lomb, GlassesOff/Innovision, Re- Focus, RPS, Shire, Sun Pharma, and TearLab. Dr. Starr is a member of the speakers bureau of Alcon, Allergan, and Bausch + Lomb He has received research funding from RPS and travel expense reimbursement from TearLab. Elizabeth Yeu, MD, has an investment interest in Modernizing Medicine and RPS. She has received a retainer, ad hoc fees or other consulting income from and is a member of the speakers bureau of: Abbott, Alcon, Allergan, BioTissue, iOptics, Shire, and TearLab. Dr. Yeu has received a retainer, ad hoc fees or other consulting income from: ArcScan, Bausch + Lomb, Kala, Ocular Therapeutix, OcuSoft, Omeros, and TopCon. She has received research funding from BioTissue, iOptics, and Kala. Staff members: Kristen Covington and Laura Johnson have no ophthalmic-related financial interests. Supplement to EyeWorld September 2017 allows us to examine patients' lids and meibomian glands. Further- more, we can show our findings to patients so they understand their disease, especially if they have no symptoms. we are more likely to diagnose the condition accurately. In addition to point-of- care tests, I use lissamine green staining. We perform dynamic meibomian gland imaging on al- most every surgical candidate and patient with dry eye symptoms. It surgery, refractive cataract sur- geons are less likely to achieve the surgical outcomes patients seek. Diagnostic advances Dry eye is often misdiagnosed, and if patients are treated for the incorrect disease, they will not respond to therapy. To improve treatment, oph- thalmologists need to make the correct diagnosis the first time, but we need to do it simply and efficiently. Point-of-care tests have changed the way we diagnose dry eye. Ophthalmologists should empower technicians to order and perform this testing based on patients' symptoms. Combin- ing these results with our other findings from the examination, Advanced OSD diagnostics and treatments play key role in surgical results P atients older than 70 years have an almost 100% chance of having meibomian gland disease, and many also have aqueous deficiency dry eye. If dry eye remains undiagnosed or is not treated properly before by Eric Donnenfeld, MD Preoperative strategies help clinicians achieve optimal postoperative outcomes Eric Donnenfeld, MD " Refractive cataract surgeons cannot perform premium surgery without a premium ocular surface. " —Eric Donnenfeld, MD Supported by unrestricted educational grants from Allergan, Shire Pharmaceuticals, TearLab, and TearScience Click to read and claim CME credit Supplement to EyeWorld March 2018 surface," Preeya Gupta, MD, said. There is some- times confusion on how to use these tests. They can help to push the needle in terms of your Supported by unrestricted educational grants from Shire, TearLab, and TearScience Customizing modern OSD therapies to individual patient needs Accreditation Statement This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continu- ing Medical Education through the joint providership of the American Society of Cataract and Refractive Surgery (ASCRS) and EyeWorld. ASCRS is accredited by the ACCME to provide continuing medical education for physicians. Educational Objectives Ophthalmologists who participate in this activity will: • Evaluate current protocols for screen- ing, diagnosis, and classification of OSD • Modify protocols as necessary • Match therapeutic classes to associated diagnosis Designation Statement The American Society of Cataract and Refractive Surgery designates this enduring materials educational activity for a maximum of 1.0 AMA PRA Category 1 Credits. ™ Physicians should claim only credit commensurate with the extent of their participation in the activity. Claiming Credit To claim credit, participants must visit bit.ly/2E60E7R to review content and download the post-activity test and credit claim. All participants must pass the post-activity test with a score of 75% or higher to earn credit. Alternatively, the post-test form included in this supplement may be faxed to the number indicated for credit to be awarded, and a certificate will be mailed within 2 weeks. When viewing online or downloading the material, standard internet access is required. Adobe Acrobat Reader is needed to view the materials. CME credit is valid through July 31, 2018. CME credit will not be awarded after that date. Notice of Off-Label Use Presentations This activity may include presentations on drugs or devices or uses of drugs or devices that may not have been approved by the Food and Drug Administration (FDA) or have been approved by the FDA for specific uses only. ADA/Special Accommodations ASCRS and EyeWorld fully comply with the legal requirements of the Americans with Disabilities Act (ADA) and the rules and regulations thereof. Any participant in this educational program who requires special accommodations or services should contact Laura Johnson at ljohnson@ascrs. org or 703-591-2220. Financial Interest Disclosures Zaina Al-Mohtaseb, MD, has received a retainer, ad hoc fees or other consulting income from Allergan and is a member of the speakers bureau of Alcon. Preeya Gupta, MD, has received a retainer, ad hoc fees or other consulting income from Alcon, Allergan, Aurea, Bio-Tissue, Johnson & Johnson Vision, NovaBay Pharmaceuticals, Ocular Science, Shire, TearLab, and TearScience. Terry Kim, MD, has an investment interest in Ocular Therapeutix, Omeros, and TearScience. He has received a retainer, ad hoc fees or other consulting income from Acucela, Aerie, Alcon, Allergan, Avellino Labs, Bausch + Lomb, BlephEx, CoDa Therapeutics, Foresight Biotherapeutics, Kala Pharmaceuticals, NovaBay, Novartis, Ocular Systems Inc., Ocular Therapeutix, Oculeve, Omeros, PowerVision, Presbyopia Therapies, Shire, TearLab, and TearScience. Francis Mah, MD, has an investment interest in Sydnexis. He has received a retainer, ad hoc fees or other consulting income from Abbott, Aerie, Alcon, Allergan, Bausch + Lomb, CoDa, NovaBay, Ocular Science, Okogen, Omeros, PollyActiva, Shire, Sun Pharma, and TearLab. Dr. Mah is a member of the speakers bureau of Abbott, Alcon, Allergan, Bausch + Lomb, Shire, and Sun Pharma. He has received research funding from Abbott, Allergan, and Ocular Science. Staff members: Kristen Covington, Laura Johnson, and Ellen Stodola have no oph- thalmic-related financial interests. continued on page 2 together information in addition to a slit lamp exam. "I look at diagnostic and point-of-care testing as getting a snapshot of the health of the ocular pacts patient satisfaction in postop cataract and refractive patients. Other survey questions asked about primary therapy for moderate and severe dry eye, as well as treat- ment options for meibo- mian gland dysfunction (MGD). Additionally, 83% of respondents indicated that they would find an algorithm for ocular sur- face diagnostics valuable. A lot of patients who have dry eye are often asymptomatic, Zaina Al-Mohtaseb, MD, said. This is why in addition to subjective questionnaires, objective tests like MMP-9 and osmolarity are im- portant. Physicians have access to various diag- nostic tests that can be used collectively to piece Clinical Survey and introduction Terry Kim, MD The ASCRS Clinical Survey was completed in May 2017 to assess clini- cal opinions and practice patterns. Data from the survey indicates that 91% of ASCRS respondents think mild to moderate dry eye significantly im- " Data from the survey indicates that 91% of ASCRS respondents think mild to moderate dry eye significantly impacts patient satisfaction in postop cataract and refractive patients. " —Terry Kim, MD

• Cover