Eyeworld

EW MEETING REPORTER 98 EyeWorld/ASCRS reports from the 2019 Surgical Summit, January 31–February 2, Park City, Utah billing premium cataract surgery and patient education/informed consent. Safe harbor with refractive cataract billing means that addi- tional services must be for refractive surgery performed in addition to traditional cataract surgery, and spe- cifically for the treatment of astig- matism and/or presbyopia. Services that qualify under this safe harbor include limbal relaxing incisions (LRIs) that are manual or femtosecond laser created, toric IOLs, and presbyopia IOLs. However, he noted that some services that do not qualify include ORA (Alcon) by itself, femtosecond laser for a mono- focal IOL without LRIs, and use of technologies like Callisto (Carl Zeiss Meditec, Jena, Germany), Verion (Al- con), or TrueVision (Santa Barbara, California) for monofocal IOLs with- out the treatment of astigmatism. Dr. Raviv also highlighted the importance of having refractive packages for astigmatism or presby- opia. These can include additional preoperative diagnostic testing, in- traoperative services, and additional postoperative services. Dr. Raviv went on to discuss patient education and informed consent. He tells patients the goal is to minimize, not eliminate, specta- cle use, and he talks to them about nighttime visual phenomenon and quality, as well as the need for addi- tional procedures. longer loop design along with the Malyugin ring now allow for more controlled cataract surgery in pseu- doexfoliation patients. Dr. Condon said Ahmed seg- ments provide the ultimate equa- torial bag and zonular support, but there was a time when they were not available in the U.S. Another challenge with these cases is cortical cleanup. Instead of pulling radially, Dr. Condon described the development of a tan- gential, banana peel-type approach that puts less stress on the zonules. He discussed management of late in-the-bag dislocation. His pref- erence is to keep the existing IOL and fix the IOL/bag complex. Iris fixation and in-the-bag ab externo scleral fixation are both options. For the latter, Dr. Condon described using 16-mm long curved needles and 9.0 polypropylene to go through the sclera, pushing out the cornea, as a "simple, retrievable suture idea." This, he said, is his "go- to approach" for a dislocated single piece lens in the capsular bag. Editors' note: Dr. Condon has no finan- cial interests related to his comments. Consent in refractive cataract surgery Tal Raviv, MD, New York, discussed consent in refractive cataract sur- gery. He highlighted safe harbor for visual field test with foveal sensitiv- ity turned on to help assess if the patient's poor vision is due to the cataract or to reduced foveal sensi- tivity as a result of glaucoma. Other considerations in these patients include the iris being more prone to poor dilation and possibil- ity of floppy iris syndrome; vitreous being present after previous glauco- ma surgery; and the nerve might be susceptible to IOP elevations. To the latter point, Dr. Radcliffe said three doses of acetazolamide within the first 24 hours after cataract surgery in patients with severe glaucoma is the "single thing most likely to preserve vision in this tumultuous time." Dr. Radcliffe also cautioned that refractive targets can be harder to hit in these patients due to extreme axi- al lengths, IOL instability, abnormal effective lens position due to ante- rior segment anatomy or pseudoex- foliation, and possible axial length change from IOP reduction. Editors' note: Dr. Radcliffe has finan- cial interests with Alcon and Glaukos (San Clemente, California). The Alan Crandall Lecture Garry Condon, MD, Sarasota, Flori- da, presented the Alan Crandall Lec- ture on "Pseudoexfoliation: Evolving IOL Fixation." This systemic condition that always presents bilaterally has a neu- ropeptide now under investigation to potentially treat the underlying cause of the disease. Pseudoexfoli- ation glaucoma sees damage that progresses more rapidly, is more severe at the time of diagnosis, and has more frequent need for surgery compared to primary open angle glaucoma, Dr. Condon said. It is more resistant to medication and has been excluded from all of the MIGS trials, but cataract surgery lowers IOP in these patients. However, there is a higher risk for intraoperative challenges (poor pupil dilation and zonular laxity) and postoperative complications (IOL/bag complex dislocation). Iris hooks in cataract surgery had their limitations because they dislodged and didn't support the bag, Dr. Con- don said. Capsule retractors with a March 2019 View videos from the 2019 Surgical Summit: EWrePlay.org Douglas Koch, MD, discusses how IOL calculation challenges are being met. continued on page 100

• Blank Page
• Blank Page (1)