JUN 2013

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

Issue link: https://digital.eyeworld.org/i/137624

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September 2011 Groopman said. "You can't accurately understand the impact that a certain outcome will have if you've never experienced it." There are a variety of medical mindsets a patient can have. She said people can be minimalists or maximalists. Some patients prefer a naturalism approach, where they would rather take a medication or treatment made from natural materials. This differs from the technology approach, where a patient prefers the most up-to-date technology and updated medicine. Finally, patients can be believers or doubters, where they are either confident or skeptical that a treatment will be successful. To access a particular person's mindset, look at the numbers and attempt to determine how they apply to a particular individual, and consider stories of people who have similar backgrounds and mindsets. Experts debate the best options for glaucoma patients with cataract Attendees at a symposium titled, "Cataract surgery in the glaucoma patient: How to select the best option for my patient?" were treated to a lively series of presentations by cataract and glaucoma experts, each arguing in favor of various procedures. David F. Chang, MD, Palo Alto, Calif., Steven D. Vold, MD, Fayetteville, Ark., and Robert J. Noecker, MD, Pittsburgh, presented arguments for various combined procedures for early to moderate glaucoma patients with cataracts. They included phaco with ab interno stenting of Schlemm's canal, phaco with ab interno trabeculectomy, and phaco with endoscopic cyclophotocoagulation, respectively. Steven Dewey, MD, Colorado Springs, Colo., argued for why phaco alone is the best approach. After hearing all the arguments, the audience voted Dr. Chang the winner. Dr. Chang presented various studies that showed that when phaco is combined with the iStent (Glaukos, Laguna Hills, Calif.), there is an additional reduction in IOP versus phaco alone. There is also a better chance of reducing glaucoma medications. The procedure is safe, with no hypotony or bleb, he said. It does not increase inflammation, there's no change in recovery and no change in astigmatism. Phaco with the iStent also provides room for future options as it spares the conjunctiva and a trabeculectomy may be performed later on if needed, he said. Experts also debated which combined procedures are best for advanced glaucoma patients with cataracts. Douglas J. Rhee, MD, Thomas Samuelson, MD, leads a discussion on glaucoma innovations. Source: EyeWorld Boston, Ike K. Ahmed, MD, Toronto, and Paul Harasymowycz, MD, Montreal, argued for phaco and trabeculectomy, phaco and minishunt, and phaco and canaloplasty, respectively. Reay H. Brown, MD, Atlanta, argued for doing cataract surgery alone. The audience voted Dr. Brown the winner in this segment. Dr. Brown said that especially in advanced glaucoma patients, surgeons should keep it simple and do cataract surgery alone because "these very delicate damaged eyes are so vulnerable to the complications that are common with glaucoma surgery." Pardon the ophthalmology ... Taking its hat off to sports cable network ESPN, the ASCRS Cornea Committee presented "Pardon the Ophthalmology," hosted by moderators Edward Holland, MD, Cincinnati, and Terry Kim, MD, Durham, N.C. In this highly interactive symposium, Drs. Holland and Kim presented various corneal abnormalities as seen on the slit lamp, topography, or optical coherence tomography (OCT) and had panelists debate how they would diagnose and treat. An audience response system ensured the audience was an equal participant. Panelists were: John A. Hovanesian, MD, Laguna Hills, Calif.; A. John Kanellopoulos, MD, Athens, Greece; Francis M. Mah, MD, La Jolla, Calif.; Neda Shamie, MD, Los Angeles; Christopher E. Starr, MD, New York, and David T. Vroman, MD, Charleston, S.C., with a special appearance by ASCRS president Eric D. Donnenfeld, MD, Long Island, N.Y. The moderators started with several "funny Ks" cases, including epithelial basement membrane dystrophy (EBMD), Salzmann's nodules, meibomian gland dysfunction (MGD), and forme fruste keratoconus (FFKC). "Unless you're specifically looking for EBMD, it's hard to notice," Dr. Shamie said. "But it does need to be treated before cataract surgery." EW MEETING REPORTER 63 "EBMD will wreak havoc on your IOL calcs," Dr. Vroman said. Panelists and audience members agreed superficial keratectomy is an easy treatment. In cases of Salzmann's, treat with superficial keratectomy "and then wait at least a month before doing your IOL calculations," Dr. Kim said. Dr. Kanellopoulos is also using autologous serum to treat these nodules. MGD "will impact your topography," Dr. Holland said. Numerous treatment options were discussed, but the general consensus is MGD must be treated before cataract surgery. In FFKC, if the patient is stable, most would combine phaco with a toric lens, but if the FFKC has progressed, collagen crosslinking followed by phaco is recommended. "Never do laser vision correction or a limbal relaxing incision because you're destabilizing the cornea," Dr. Starr said. Dr. Vroman added knowing the contact lens status of the patient is helpful as well. Francis W. Price Jr., MD, Indianapolis, was the keynote speaker and discussed Descemet's membrane endothelial keratoplasty (DMEK) compared to Descemet's stripping (automated) endothelial keratoplasty (DSAEK). "DSAEK has become the standard of care, but we've found DMEK is our standard of care simply because it's a superior procedure," he said. "DSAEK changes people's lives. They're able to work within one to three weeks. We're finding with DMEK, patients are seeing 20/20 to 20/40 on postop day two." To those who say DMEK is a difficult procedure to learn, Dr. Price recalled when ophthalmology began the move from extracap to phaco, "everyone said how hard phaco was—at first. When DSAEK came out, people said that was hard, too." He said patience, practice, and fluidics are the keys to successful DMEK, and that thicker donor tissue (from older eyes) is easier to manipulate and unfold.

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