Eyeworld

71 August 2018 EW MEETING REPORTER pia, and the need for the ectasia to be stable. The main prerequisite for toric IOL placement in keratoconus eyes is a stable, non-progressive ec- tasia. The surgeon should wait and observe corneas of young patients and discuss realistic expectations. Mitchell Weikert, MD, Hous- ton, discussed innovations in toric IOLs, saying that outcomes largely depend on accurate corneal astig- matism measurements, accurate marking of the corneal meridians, and accurate alignment of the IOL. At least 20% of patients have astigmatism up to 2 D that needs correction, using one of the three current platforms: AcrySof (Alcon, Fort Worth, Texas), Tecnis (John- son & Johnson Vision, Santa Ana, California), and Trulign (Bausch + Lomb). He said that the preopera- tive measurements are key and that different devices help offer qualita- tive and quantitative advantages. He warned against devices that only measure the anterior cornea without including posterior corneal measure- ments and recommended the use of the cases that present for re- fractive surgery, and according to George Chang, MD, Hong Kong, femto phaco is the procedure of choice. In more than 3,000 cases of femto phaco that were carried out as part of the Hong Kong Experience using the VICTUS femtosecond laser (Bausch + Lomb, Bridgewater, New Jersey), surgeons needed to follow three steps to treat astigmatic eyes: get good centration (meaning good eye position with no tilting), capture the corneal steep axis (eye drops, reference mark, and capture), then perform astigmatic keratotomy (AK). He said that his anterior penetrating AK technique is simple and safe and allows for more astigmatism correc- tion by enlarging the main wound. The use of toric IOLs in eyes with keratoconus presents a special case scenario, and according to Gaurav Prakash, MD, Abu Dhabi, United Arab Emirates, it is import- ant to identify which patients stand to benefit from them. The unique refractive challenges in keratoconus include the need for cornea-sparing procedures, the frequent combina- tion of astigmatism and high myo- Will the femtosecond laser replace traditional phaco technolo- gy? No, Dr. Nagy said, but he does think it can provide a safer, effective cataract surgery with more stable and predictable outcomes. Dr. Nagy said he "dreams of a compound femtosecond laser" for cornea and cataract use and looks forward to the use of femtosecond technology for IOL adjustment as well. Cedric Schweitzer, MD, PhD, Bordeaux, France, took the opposite stance. "I'm going to show you that today, very precise cuttings do not provide meaningful results for pa- tients," he said. In terms of complications, posterior capsule rupture (PCR) is the most common intraoperative complication, but given the stage in which it usually occurs, Dr. Sch- weitzer said, use of the femtosecond laser would not necessarily act as a preventative measure. He cited a study that showed more PCR with FLACS than standard phaco. Can FLACS improve visual or refractive outcomes? Dr. Schweitzer said research has shown a small advantage of FLACS at 6 months postop in corrected distance visual acuity, but there was no significant difference in terms of uncorrected distance visual acuity. While it's likely that FLACS decreases the rate of IOL tilt, Dr. Schweitzer said that it's unlikely that its capsulotomy ac- tually improves lens positioning and postop anterior chamber depth. Femtosecond laser application is limited in certain cataract cases, such as small pupils, intraoperative floppy iris syndrome, corneal opaci- ties, zonular instability, and trauma, he said. There are patient flow issues and considerably more expense with FLACS. Surgical management of astigmatism Astigmatism is seen in at least 40% Dr. Narang said helps close all the gaps between the edge of the IOL and the iris tissue. A pupilloplasty is not necessary if the shape of the iris is normal and blocks the edges of the optic, Dr. Narang explained later. The secondary cannula—Dr. Narang prefers a trocar anterior chamber maintainer—is placed and pre-De- scemet's endothelial keratoplasty performed. The double infusion cannula technique prevents hypotony and intraoperative pressure fluctuations; assists in graft unrolling; promotes adherence to the recipient bed tissue; and prevents air from getting into the vitreous cavity and loss of air tamponade in the anterior cham- ber, Dr. Narang said. Experts debate controversies in cataract surgery Femtosecond laser-assisted cata- ract surgery (FLACS), intracameral antibiotics, extended depth of focus (EDOF) and trifocal IOLs, and safety of refractive lens exchange were debated during "Controversies in Cataract Surgery." "Femtosecond cataract surgery is still a burning issue in ophthal- mology," said Zoltan Nagy, MD, Budapest, Hungary, taking a pro- FLACS stance. Throughout his presentation, Dr. Nagy cited research that he thinks shows the benefits of using femtosecond technology in cataract surgery. The femtosecond-created capsulotomy is more accurate and reproducible in diameter and cir- cularity, he said, resulting in better centration and less lens tilt. Dr. Nagy also showed data that suggest FLACS results in less trauma to corneal endothelial cells, less increase in macular thickness, more predictable corneal incisions, and more predict- able surgically induced astigmatism. What's more, the femtosecond laser can reduce phaco energy in the eye by fragmenting the lens. View videos from the 2018 WOC: EWrePlay.org Kendall Donaldson, MD, discusses the pros and cons of femtosecond laser-assisted cataract surgery. continued on page 72

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