Eyeworld

81 November 2018 EW MEETING REPORTER it is only currently approved in the U.S. for spherical myopia. On the topic of "Intracameral prophylaxis should be mandatory," Eric Donnenfeld, MD, Rockville Centre, New York, argued that it should be mandatory. He highlighted studies demon- strating how the use of intracameral prophylaxis has reduced the rate of postoperative endophthalmi- tis following cataract surgery. He mentioned studies by ESCRS, the Aravind Eye Hospital in India, and more, which compiled thousands of cases to show reduction in the endophthalmitis rate using cefurox- ime, moxifloxacin, vancomycin, or some combination of these. It is about time intracameral antibiotics are approved in U.S., Dr. Donnenfeld said, mentioning the Topical versus Intracameral Moxifloxacin for Endophthalmitis prophylaxis (TIME) study, which is currently underway and seeks to show that intracameral moxifloxa- cin is superior to topical moxifloxa- cin for the prevention of postopera- tive endophthalmitis. If the study hypothesis is proven, Dr. Donnenfeld said, this will provide additional prospective evidence for the use of intracameral antibiotics. On the other side of the topic, Antoine Brezin, MD, Paris, France, discussed why intracameral prophy- laxis should not be mandatory. Dr. Brezin argued that while there has been a reduction in the rate of endophthalmitis worldwide, many factors have changed, and this may not be directly related to intracameral medication. Other factors influencing endophthalmitis, he said, are that the duration of surgery has been reduced, machines have improved, surgical theater air filtering systems have improved, incision size, IOL material, and preloading vs. manual folding, among others. Dr. Brezin said he uses intraca- meral prophylaxis, but he chooses it more because of the "fear factor" rather than because of the science behind it. EW admission and it's more efficient for OR time. For the health system, it offers shorter waiting lists and is cost effective. However, he did note some cons of bilateral surgery, including risk of endophthalmitis, TASS, and ocular hypertension (these can occur early). Late bilateral complications include refractive surprise, cystic macular edema, and corneal decompensa- tion. There may also be financial barriers for facilities and surgeons with a bilateral procedure. On the other side of the topic, Myoung Joon Kim, MD, Seoul, South Korea, questioned if bilateral cataract surgery is the way to go. He prefers to do delayed sequential cataract surgery. The greatest fear is bilateral simultaneous endoph- thalmitis, he said. TASS and corneal edema are also concerns. Although the prevention and treatment methods of endoph- thalmitis have improved, the risk still exists, Dr. Kim said. He added that there are both patient factors (immunity, blepharitis, and habits) and device factors (manufacturing, cleaning, and sterilization) that could affect both eyes. Dr. Kim said that on the surgeon side, benefits of an interval between cataract surgeries include prevention of complications, IOL selection, and customized advice. On the patient side, they can prepare mentally and physically between surgeries. Also during the session, Sri Ganesh, MD, Bangalore, India, and Terry Kim, MD, Durham, North Carolina, debated if SMILE is better than LASIK. Dr. Ganesh argued in favor of SMILE, mentioning some of the disadvantages of femto LASIK: flap-related complications, loss of sub-epithelial plexus leading to dryness, integrity of corneal biome- chanics is breached, relatively more time consuming, and minor patient discomfort. Meanwhile, Dr. Kim highlighted the high satisfaction with the LASIK procedure. He also mentioned some of the limitations of SMILE, includ- ing some safety concerns, ability to do enhancements, and the fact that Jesper Hjortdal, MD, Aarhus, Denmark, thinks that high astigma- tism of more than 6 D and post-PK astigmatism should be treated with arcuate keratotomy, while high astigmatism of up to 5 D can be treated via PRK, LASIK, SMILE, or toric IOLs. Irregular astigmatism requires topography-guided ablation and can also be addressed with the use of intracorneal ring segments. Dr. Hjortdal noted that he always keeps track of the right meridian. CSCRS symposium The Combined Symposium of Cata- ract and Refractive Societies (CSCRS) covered the topic of "Current De- bates in Ophthalmology." Juan Mura, MD, Santiago, Chile, spoke about how bilateral cataract surgery is "the way to go." He shared some of the pros and cons of performing the procedure bilaterally. First, he said that one of the main benefits from the patient perspective is faster visual rehabil- itation. Additionally, patients can avoid anisometropia between sur- geries, can have fewer postop visits, less transportation is necessary, and there is less need for accompanying family members. Dr. Mura added that there are also benefits of bilateral surgery for the hospital and health system. For the hospital, there is only one excess of 25.0 mm and will include a 5-year follow-up. Short eyes are different, accord- ing to Boris Malyugin, MD, PhD, Moscow, Russia, who reminded delegates of the distinction between nanophthalmos, microphthalmos, and relative anterior microphthal- mos. He said that complications resulting from lens-based surgery in micro- and nanophthalmic eyes was 15.5%, but those seen in nanoph- thalmic eyes (axial length below 20 mm) reached 42.9% of cases, with severe complications noted in 23.8%. He highlighted careful pre- operative evaluations and IOL power calculations. Surgery in highly hyperopic eyes is "an expert's job only," ac- cording to Walter Sekundo, MD, Marburg, Germany, who argued in favor of corneal lamellar surgery, not surface ablation, in select cases. He performs the treatment of high hyperopia (+3.0 D to +6.0 D) by means of corneal refractive surgery, including an extensive preoperative diagnostic work-up. Expected LASIK outcomes from the literature show that roughly 70% of high myopes are within 1.0 D, with a 10–20% loss of one line of Snellen, a 6% loss of two lines or more, and retreatment rates up to 10%. Refractive results for high hyperopia with SMILE seem to be similar to LASIK. View videos from the 2018 ESCRS: EWrePlay.org Oliver Findl, MD, discusses unique challenges in performing cataract and refractive phakic IOL surgery in the long eye.

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