Eyeworld

EW MEETING REPORTER 78 November 2018 EyeWorld/ASCRS reports from the 2018 ESCRS Congress, September 21–26, Vienna, Austria aqueous humor. Nearly 90% of ophthalmologists would consider sustained-release options for med- ication application, while 55% of patients would prefer to stick with eye drops. Degrees of acceptance vary according to age, region of the world, availability, prices, reimburse- ment, and adverse events. When cataract surgery goes wrong A surgical video session featured a variety of ways to deal with cataract surgery when it goes wrong. Bernardo Feijoo, MD, Lisbon, Portugal, shared a case of a posterior polar cataract, noting that there is a high rate of complications with these types of cataracts. He advised the patient prior to surgery of the risk of complications. During the procedure, Dr. Feijoo noted that his first mistake was that he was trying to do a slow and smooth hydrodissection. It seemed that this technique was working, and he was trying to avoid rotating the nucleus. Dr. Feijoo proceeded with phaco, and it seemed as though everything was fine. He began using a traditional technique and tried to create a crease that was not very deep. The chamber seemed stable at this time, with no deepening. However, Dr. Feijoo did not achieve good separation between the epinucleus and endonucleus. He normal physiology when feasible is a priority. Dr. Samuelson exer- cises caution with high outflow, low resistance surgical options that may "steal" flow from physiological pathways and cause spikes in IOP. Deciding among canal, transscleral, or supraciliary approaches is not a simple matter of device label and disease severity. Although severity is important, it is only one factor along with compliance and toler- ance with medications and most importantly, the likelihood and velocity of progression. Trabeculectomy is alive and well, according to a presentation given by Ingeborg Stalmans, MD, PhD, Leuven, Belgium. Still con- sidered the "gold standard," trabe- culectomy continues to effectively lower IOP, and although there are fewer and less severe complications thanks to modern techniques, they continue to be a reality. Bleb surgery provides low-teen pressures but requires bleb management. Unfor- tunately, a one-size-fits-all approach to glaucoma management is not yet appropriate, she said. New glaucoma drug groups and drug delivery systems were covered by Antonio Fea, MD, Turin, Italy, who reminded delegates that 50% of an eye drop is lost immediately upon installation, 80% with reflex tearing, and that less than 5% of an active topical drug reaches the used for longer than 10 years of follow up. EC loss from 6 months to 10 years postoperatively was 16.6% in the myopia group and 21.5% in the toric group. Risk factors for increased EC loss included a shal- low anterior chamber depth and a smaller distance between the central and peripheral phakic IOL edge to the endothelium. Dr. Nuijts shared data on the explantation rate with iris-fixat- ed phakic IOLs and said that the explantation rate of the phakic IOL after 10 years was 1% in the myopic group, and the total explantation over the complete follow-up was 6% in the myopic group. Finally, Dr. Nuijts shared re- search examining if DMEK is better than ultra-thin DSAEK. In a trial he did in the Netherlands, he said there was no significance difference in visual acuity between DMEK and ultra-thin DSAEK. He thinks there are some indications that DMEK is better, but complications still seem to be higher with DMEK. Glaucoma for cataract surgeons Glaucoma specialists convened to deliberate on the present and future of glaucoma treatment. Understanding the trabecular meshwork is a crucial first step, according to James Tan, MD, Los Angeles, who spoke on his work with two-photon imaging of the distal aqueous outflow system in mice. Outflow is pulsatile and syn- chronous with the cardiac cycle. The distal outflow tract is not inert or static but a dynamic system and is its "own type" of self-regulating vas- cular system. His work demonstrated that Schlemm's canal has valves (like lymphatics), and the walls of the intrascleral plexus have smooth muscle lining (like blood vessels). Further research into this field will show whether these cells adapt post-surgically, what their effect is on MIGS outcomes, and whether they can be manipulated with drugs, among other things. Thomas Samuelson, MD, Minneapolis, shared his expertise on MIGS, noting that the risk of glaucoma surgery should not exceed the disease risk and that retaining View videos from the 2018 ESCRS: EWrePlay.org David Chang, MD, discusses posterior capsulorhexis and anterior optic capture for premium IOL cataract cases in which there is a posterior capsular complication. Sponsored by

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