Eyeworld

DECEMBER 2019 | EYEWORLD | 65 O potential to reposition themselves and incisions depending on bleb positioning. Tubes should be assessed and managed during the procedure if too long or anterior, Dr. Okeke said. During a keynote lecture on IOL power calculations, Douglas Koch, MD, Houston, sought to answer the question "can we do bet- ter?" In the literature, 70–80% of outcomes are within 0.5 D of target, Dr. Koch said, noting that the best data uses the Hill-RBF formula, resulting in 90% within 0.5 D. Sources of residual refractive error today are effective lens position (ELP) and the anteri- or and posterior cornea. Dr. Koch said that it's time to talk about IOL calculation formulas based on how they work instead of generations —geometric optics, ray tracing, artificial intelligence, and combi- nation formulas. Ideally, ray tracing formulas would be the most accurate, because they in- corporate all aberrations of the cornea and the IOL, but a major limitation is that they don't solve the ELP quandary. Corneal power also continues to be a major source of error and thus must be optimized. Other best practices for improving IOL calcu- lation accuracy, according to Dr. Koch, include using accurate devices (optical or swept-source biometry and multizone LEDs for K readings), using the best formulas, and verifying quality of raw data used in calculations. Step 1: Get any glaucoma optimized. This in- volves early placement of a tube shunt. Step 2: Correct lid abnormalities. If uncorrect- ed, there is poor prognosis for any reconstruc- tion efforts. Step 3: Suppress inflammation and autoim- mune responses, topically or systemically (can also take months to years). Step 4: Do a trial scleral contact lens. Dr. Chan said this has "revolutionized" how she's man- aged these patients. The PROSE device (Bos- tonSight) or impression molded EyePrintPro (EyePrint Prosthetics) can be used. Step 5: Ocular surface stem cell transplant. Re- place conjunctiva or stem cells. Fornix reforma- tion is important because patients can then wear protective contact lenses. Step 6: Optical cornea transplant. Continue ongoing surveillance for glaucoma, infection, corneal melt, retinal detachment, sterile vitritis, endophthalmitis, etc. Things to have in your "ocular surface optimi- zation tool box" are lubricants, anti-inflamma- tories, nutritional support, lid margin disease management, and adjuncts, Dr. Chan said. Constance Okeke, MD, Norfolk, Virginia, offered several pearls for cataract surgery in eyes with preexisting tubes or trabs. Give preop evaluations more time and thought, and address patient expectations early. MIGS could mini- mize IOP spike risk, and treat inflammation ag- gressively. Surgeons need to be prepared for the Meeting in San Francisco Deepinder Dhaliwal, MD, discusses treatment strategies for high regular and irregular astigmatism. Davinder Grover, MD, discusses existing and pipeline micro shunts. S u b s c r i b e a t E Y E W O R L D T V . C O M

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