Eyeworld

75 December 2018 EW MEETING REPORTER needed until the patient is symp- tomatic or if the patient needs his or her ocular surface optimized for surgery. It's important to let patients know that there is no real cure for blepharitis, he added. For meibomi- tis, consider culturing, eyelid wipes, and dietary supplementation. In more severe patients, serum, plasma, and scleral lenses can be part of the treatment mix. Editors' note: Dr. Jeng has no financial interests related to his comments. The latest and greatest in cataract surgery "Cataract Surgery: The Cutting Edge" provided a roundup of the latest advances in cataract surgery, moderated by Robert Osher, MD, Cincinnati. Warren Hill, MD, Mesa, Arizo- na, spoke about available IOL for- mulas and advised attendees to use the newer Olsen, Barrett, or Hill-RBF formulas. However, the addition of the Wang-Koch axial length adjust- ment to the calculations has helped improve the other formulas as well. Edward Holland, MD, Cincin- nati, shared a variety of new and upcoming treatments for cornea, including two new types of cyclo- sporine, the newly approved Oxer- vate (cenegermin, Dompé, Milan, Italy) for neurotrophic keratitis, new drug delivery systems, an artificial endothelium under development, cultured endothelial cell injection therapy, and even a 3-D printed cornea. Glaucoma is also having a re- naissance for its medication options, said Richard Lindstrom, MD, Min- neapolis. The nitric oxide-releasing prostaglandin Vyzulta (latanopros- tene bunod, Bausch + Lomb, Bridge- water, New Jersey) was recently approved, along with the rho kinase inhibitor Rhopressa (netarsudil, Ae- rie Pharmaceuticals, Durham, North Carolina). There are other glaucoma agents in Phase 2 and 3 trials, in- cluding a punctal plug that delivers medication and a bimatoprost ring, Dr. Lindstrom said. vitreous loss. Vitrectomy is actu- ally a simple and straightforward procedure, she said. There are steps and equipment that you need, but it can be completed by all cataract surgeons once you understand it. The problem, she said, is that when it's unexpected, it can be anxiety inducing for surgeons. Dr. MacDonald first stressed the importance of pressurizing the chamber and taking your hand off the eye. She spoke about the importance of injecting triamcinolone into the anterior chamber, which "allows you to see exactly what you're doing." Dr. MacDonald said it's import- ant to create a closed system (where the pressure is not fluctuating) and to remove the vitreous without pulling on it. She prefers to use a pars plana approach. If you don't feel comfortable doing a pars plana anterior vitrectomy, Dr. MacDonald recommended going to a wet lab to become more proficient in this technique. Editors' note: Dr. MacDonald has financial interests with Perfect Lens (Irvine, California) and ianTECH (Reno, Nevada). Dry eye requires individualized treatment Moderate to severe dry eye disease is equivalent to a disabling hip fracture or severe angina in terms of quality of life, said Bennie Jeng, MD, Balti- more, who shared dry eye advances during the "Hot Topics of the Ocular Surface" session. Treatments for dry eye have evolved significantly, and ophthalmologists should focus on treating the underlying cause of dry eye and not just the symp- toms, Dr. Jeng said. Sometimes this means having patients stop the use of medications that add toxicity to the ocular surface. Although punctal plugs are an option for some dry eye patients, Dr. Jeng does not like to use them until the ocular surface health improves. Many patients have dry eye caused by blepharitis, and that's when Dr. Jeng focuses on treatments that provide patients the most comfort. However, he also said treatment for blepharitis is not Dr. Olson thinks that femto is about the same as manual. He said there are two certainties: FLACS takes more time, and it's more expensive. He also said that femto could cause a problem if surgeons depend too much on the laser to do cases that are beyond their learning curve and then don't know what to do if complications arise. "You have to be as good with manual as you are with femtosecond," he said. It's a mistake to assume that femtosecond is going to "do it all," he said. Dr. Ayres reiterated that he loves his laser and said that he does both manual and femto cases. He thinks that lasers haven't been given enough time yet, but he admitted that he doesn't think femto lasers will stay the way they are now. Audience members ultimately agreed with Dr. Al-Mohtaseb, with more than two-thirds agreeing that they think femto will "die a slow death." Editors' note: Dr. Ayres and Al- Mohtaseb have no financial interests related to their presentations. Managing complications The popular "Ophthalmic Premier League" session was back again, with presenters sharing videos cases of complicated cases. Susan MacDonald, MD, Boston, discussed how to manage Dr. Al-Mohtaseb said that femto seems to show higher postoperative complication rates. Usually, you would pick your "best cases" for femto, she said, particularly pre- mium cases and those that are less complicated. Is the femtosecond laser cost effective? Dr. Al-Mohtaseb argued that it's not. She pointed to pub- lished data from John Berdahl, MD, that indicated the laser costs more than $400,000, and utilization costs are about $70,000 per year. With that, you would have to do a large number of cases to just break even, she said. Following arguments from Dr. Ayres and Dr. Al-Mohtaseb, a panel weighed in on the topic as well. Elizabeth Yeu, MD, Norfolk, Virginia, argued that some of the data published was from earlier generation femto platforms. With advancements, there are certainly refractive advantages of using the laser, she said. Dr. Yeu added that lens soften- ing and fragmentation patterns have improved and use a reduced amount of ultrasound energy, which is safer for the cornea. Randall Olson, MD, Salt Lake City, said there has been a lot of potential for the femto laser, but studies just haven't supported this. It's hard to see any advantage in out- comes and complications, he said. View videos from the AAO Annual Meeting: EWrePlay.org Eric Donnenfeld, MD, discusses innovations in drug delivery of anti-inflammatories in cataract surgery. continued on page 76

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