Eyeworld

75 August 2018 EW MEETING REPORTER Shouldn't: Updating Our Clinical Approach to Cornea and External Diseases." Bennie Jeng, MD, Baltimore, and Marian Macsai, MD, Glenview, Illinois, chaired the session, which highlighted topics such as deciding if you should use steroids for bac- terial keratitis, pterygium excision, repeat PK for failed graft, DMEK, and the KPro. W. Barry Lee, MD, Atlanta, shared his tips in handling pterygi- um. He first highlighted some of the goals when performing surgery on a pterygium: remove the pathology, provide adequate cosmetic appear- ance, avoid recurrence, and prevent long-term complications. His first tip was to avoid a bare sclera technique. There are several reports now on why you should not do this, he said. There are statistical- ly higher recurrence rates with this technique than using a graft, Dr. Lee said. He next recommended that physicians avoid beta radiation. Dr. Lee recognized that this might be a "tricky" tip because there are a number of randomized controlled trials that show that the first three surgical goals are met with this ap- proach, but he said that long-term complications become a concern. Follow-up only goes to 6 months or a year, and you don't see radiation damage sometimes until 10–20 years down the road, Dr. Lee said. He recommended avoiding mitomycin-C (MMC), which he also noted might be a controversial tip. If you can do a nice grafting tech- nique appropriately, Dr. Lee doesn't think MMC is needed. He next suggested that you should "always use a conjunctiva graft when possible." There is less recurrence and better cosmetics with conjunctiva, he said. The last tip was to not do combined cataract surgery and pterygium removal. Dr. Lee removes the pterygium first then performs cataract surgery when imaging normalizes, but he recognized that some cases may require this plan to be adapted. EW Progression in 2030, Dr. Levin said, is addressed through self-ad- ministered, virtual visual field tests, next-generation, objective visual field testing, and quality of life testing. Structural progression is assessed with RGC analysis. By 2030, Dr. Levin predicted that neuropro- tective drugs will be used for glau- coma and other optic neuropathies, but he said the number of people who need glaucoma treatment will likely expand, and there will still be a need for the same or more surgery. In terms of glaucoma lasers in 2030, Michael Belkin, MD, Tel- Aviv, Israel, presented evidence that irradiation of the optic nerve head has been used for neuroprotection with changes resulting in the visual field. Other research has found that red light enhances mitochondrial function to benefit cell survival. Dr. Belkin said that lasers in 2030 will likely still be used for periph- eral iridotomies, iridoplasty, and endoscopic/transscleral cyclophoto- coagulation. He also predicted that selective laser trabeculoplasty would become a standard, first-line, and repeat treatment for most types of glaucoma due to deficiencies with eye drop therapy. Chungkwon Yoo, MD, PhD, Seoul, South Korea, discussed IOP measurement and monitoring in the future. While Goldmann applana- tion tonometry is the gold standard now, with IOP usually measured 2–6 times a year in the clinic, research has shown IOP fluctuation (diurnal and positional) and related glauco- ma progression. Peak IOP, Dr. Yoo said, often occurs outside of office or clinic hours. As such, newer modalities for IOP monitoring are either already on the market or in testing. Home tonometry is already available, allowing individuals to test their IOP on a daily basis. Continuous, 24- hour IOP monitoring with a contact lens is also available, and implant- able IOP sensors are in development. Symposium highlights topics in cornea and external disease A symposium co-sponsored by the Cornea Society was titled "Things We Still Do That We Probably "By 2030, there is a very realistic possibility that we could automate our straightforward glaucoma management," Dr. Thomas said, which could allow physicians to "hand over onerous, straightforward work to computers" and allow the surgeon to "spend more time with patients who need your expertise most." Dr. Thomas added that he thinks ophthalmology, and glauco- ma specifically, is well positioned to be the first to fully automate a clinic using AI. "Although, for a long time every decision needs to be scruti- nized by a human as well," he said. Leonard Levin, MD, PhD, Montreal, Canada, presented as if he was reporting on the current state of neuroprotection in glaucoma in 2030. In 2030, he said, we don't talk about higher target IOP, we talk about lower treatment intensity. While IOP in 2018 was measured a few times a year in the clinic, in 2030, continuous, noninvasive IOP monitoring is taking place, Dr. Levin imagined. Treatment intensity is a combination of IOP lowering meth- ods and neuroprotection, targeted to decrease retinal ganglion cell (RGC) death and stress. RGC cell death and stress is measurable in 2030, allow- ing glaucoma specialists to initiate or change treatment based on these metrics vs. in response to IOP. what happened. Dr. Chang added that at 1-month postop, the lens was well centered, and he concluded by asking the audience how they would react if the patient had experienced 15 degrees of misalignment and was symptomatic. Most (67%) said they would leave the patient alone and correct with spectacles, while 3% would reposition in the bag, 19% would reposition in the bag and do reverse optic capture, 6% would do an IOL exchange with a three-piece IOL in the sulcus, and 6% would refer the patient. Glaucoma in 2030 Where will glaucoma diagnosis and treatment be by 2030? Peter Thom- as, MD, PhD, London, U.K., thinks that glaucoma is well placed to take advantage of artificial intelligence (AI), due to the existing focus on quantifying patients, thus driving the formation of datasets that could be used to create this AI. There are already a few areas where glaucoma could be taking advantage of AI, Dr. Thomas said: examination of the disc, inspection of the visual field, and monitoring for progression. Yet there are still many other applications in glauco- ma where the field of AI would need to move forward. In order to get there, what's needed are very large datasets. View videos from the 2018 WOC: EWrePlay.org David Chang, MD, discusses a study on toric IOL alignment and rotation, looking at two different models of IOLs.

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