Eyeworld

EW MEETING REPORTER 120 EyeWorld reports from the 2018 Combined Ophthalmic Symposium (COS), August 24–26, Austin, Texas October 2018 ly thin measurements. He also de- scribed some of the aspects of RNFL thickness maps and deviation maps and what they show, as well as the TSNIT graph, where RNFL thickness is overlaid on an age-related norma- tive data background. Dr. Patrianakos noted that there may be an average of 0.2 μm/year change in RNFL. During his presentation on "Making Sense of MIGS," Thomas Samuelson, MD, Minneapolis, de- scribed why he approaches glauco- ma surgery the way he does. Dr. Samuelson thinks that the risk of glaucoma surgery should not exceed the disease risk, and he prefers to retain normal physiology when feasible. He will also exercise caution with high outflow, low resis- tance pathways. Dr. Samuelson said it's import- ant to utilize diagnostic precision; you need to estimate disease veloci- ty. Communication is key, especially in letting the patient know that no procedure can cure glaucoma and there is no one procedure that is the safest and most effective. In another presentation, Dr. Patrianakos discussed some of the factors that help him choose which procedure to use for glaucoma patients. He stressed the impor- tance of becoming comfortable with the procedures, knowing specific indications, safety and efficacy, how a procedure fits with your practice, and the expense. Dr. Patrianakos stressed the importance of knowing how to perform intraoperative gonioscopy, mastering one procedure (which he said makes it easier to incorporate other procedures), not giving up after your first adverse outcome, and reaching out for support. Dr. Patrianakos highlighted practice fit and tailoring procedures to your practice needs. For mild/ moderate, well-controlled glaucoma, Cataract surgery: upping your game The first session of the program covered a variety of cataract surgery topics. Jonathan Rubenstein, MD, Chicago, shared pearls for dense and white cataracts. When dealing with dense brunescent cataracts, Dr. Rubenstein stressed that you need adequate pupil dilation and to protect the cornea. He suggested a technique begin- ning with bowling out the superfi- cial cortex/nucleus. Use a chopping technique (vertical and/or horizon- tal) and use a capsular tension ring if needed. Dr. Rubenstein added that the femtosecond laser may be helpful in these cases to get through the lens, but you may not be able to get adequate OCT imaging. Surgeons may encounter different types of white cataracts. These could include a white lens with a hard nucleus, white corti- cal cataracts with cortical-capsular adhesions and dense PSC and/or ASC, a partially liquefied intumes- cent swollen cataract, or a liquefied morgagnian cataract. Dr. Rubenstein suggested several techniques for managing white cataracts. Lower the pressure preop and decompress the capsular bag. Using trypan blue dye, using extra viscoelastic to keep pressure on the anterior capsule, using a slower and smaller capsulorhexis, rocking the lens gently during hydrodissection to release fluid from behind the lens, and using a horizontal chop or stop and chop phaco are helpful tech- niques in these cases. Editors' note: Dr. Rubenstein has finan- cial interests with Alcon (Fort Worth, Texas) and Shire (Lexington, Massa- chusetts). Glaucoma diagnostics, medical and surgical management Thomas Patrianakos, DO, Chicago, offered several tips on visual field interpretation: know your reliabil- ity indices, use the global indices, recognize glaucomatous scotomas, be familiar with common artifacts and testing errors, and be able to correctly determine progression. Dr. Patrianakos discussed tips for RNFL and optic nerve exam. He described his step-by-step approach looking at signal strength, RNFL thickness/deviation map, TSNIT graph/quadrant analysis, tomogram, and tabular data. He noted that in terms of signal strength, 7 or greater is a good scan, but less than that could lead to false- EyeWorld reports from the 2018 Combined Ophthalmic Symposium continued on page 122

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