JUN 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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September 2011 vantages of the triple procedure is that surgeons are preventing a prolonged recovery period with little compromise in visual outcomes. Dr. Ayres performs a three-plane incision (about 4 mm) but said his effective incision is only 2.2-2.8 mm. "Make sure your paracentesis is steep and peripheral," he advised. "Make your capsulorhexis smaller than the optic," and keep the IOL in the bag to help prevent anterior chamber shallowing during graft surgery. When to consider torics Should toric IOLs be considered if a patient has abnormal topography? Yes, said Chaz Reilly, MD, San Antonio, at Cornea Day 2013. However, surgeons have a better chance of success if they create realistic patient expectations. "Further, make sure the magnitude and axis of cylinder are in agreement between the corneal topography and refraction. Make sure there's reasonable visual potential, too—beware of meridional amblyopia, consider anisometropia, and be aware of how the posterior cornea contributes to cylinder," Dr. Reilly said. Mild cases of keratoconus (those that can be corrected with spectacles) can also be considered for toric lenses, he said. Most premium brands and services are customizable, but that's not the case with toric lenses, and that creates a potential issue, said Michael W. Belin, MD, Tucson, Ariz. Toric IOLs compensate for the corneal astigmatism on the lens plane, while rigid gas permeable (RGP) lenses correct the astigmatism on the corneal plane. "In my opinion, a toric IOL is contraindicated in patients with irregular, asymmetric, or unstable corneas, or in patients who have a visual axis that's off-center," he said. The "single most important and underutilized diagnostic test we have is an RGP diagnostic fit." Toric IOLs can be a good fit if the best corrected acuity equals what can be achieved with an RGP. "Spherical, monofocal lenses may be a better option in patients with iris or pupil abnormalities," he said. "The 'premium' IOLs are not always 'better,' and in some complex cases may result in worse vision." Glaucoma Day Sustained release drug delivery systems may be the wave of the future for glaucoma patients, although such systems are still four or five years away, predicted Iqbal "Ike" Ahmed, MD, Toronto, at ASCRS Glaucoma Day. Medication use and adherence are major reasons why alternate drug delivery systems could work well in glaucoma patients, he said. Major goals of sustained drug delivery systems are to deliver drugs to the site of action, increase efficacy, and improve clinical outcomes, Dr. Ahmed said. However, questions remain regarding how difficult it will be for patients to use sustained delivery systems and how long the various alternatives will deliver the target medication. Dr. Ahmed informed attendees of various drug delivery systems in development, including a latanoprost-eluting contact lens, a drug-eluting punctal plug system, mucus penetrating nanoparticles, and the Durasert Glaucoma Implant (pSivida, Watertown, Mass.). in these difficult cases, said Garry P. Condon, MD, Pittsburgh. In the 2013 Stephen A. Obstbaum, MD, Honored Lecture, "Pseudoexfoliation: My Life as a 'Zonulist'—What We Know, Don't Know, and Shouldn't Show," Dr. Condon outlined lessons that can assist in these cases. His first lesson is that PEX "produces the meanest form of [openangle glaucoma]." PEX patients require lower IOL, closer monitoring, and typically more surgery than OAG cases. PEX also has a higher tolerance to medical therapy, but does respond to laser treatment, Dr. Condon said. The second lesson is to take the stress off the surgeon and the zonule. He discussed different options available to do so: "Use the best capsule support you can," he said. The third lesson is that in PEX cases, a ring is not always the best option. He showed surgical video of capsular tension rings (CTR) causing issues that sabotage the very point of using them. "If you are approaching patients with pseudoexfoliation and cataract, EW MEETING REPORTER 59 because they have weak zonules to start with, I would avoid using a standard CTR … at the outset of the case because of the evidence that these can actually cause loss of zonular support prior to starting the [phacoemulsification]," he said. He said lesson four, in turn, is "know when you've met your match" and plan accordingly. Members can expect many more educational opportunities from ASCRS The world of medicine continues to evolve and, in many ways, it is the best of times and the worst of times, said incoming ASCRS president Eric Donnenfeld, MD, East Meadow, N.Y., at the ASCRS Opening General Session. "Substantial changes in healthcare delivery, access to patients, and monitoring are impacting the daily lives of every ophthalmologist and most importantly the patients we care for," he said. ASCRS has and will continue to step forward, represent the needs of ophthalmologists, voice their opin- Lessons in pseudoexfoliation Knowledge of different aspects of treating pseudoexfoliation (PEX), including its major risk factor of weak zonules, can assist in best outcomes Donald Tan, MD, and Terry Kim, MD Source: EyeWorld

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