Eyeworld

38 | EYEWORLD | JUNE 2022 by Ellen Stodola Editorial Co-Director About the physicians Dimitri Azar, MD President and CEO Twenty Twenty Therapeutics South San Francisco, California Reay Brown, MD Atlanta Ophthalmology Associates Atlanta, Georgia Clara Chan, MD Assistant Professor Department of Ophthalmology and Vision Sciences University of Toronto Toronto, Canada Steven Dell, MD Dell Laser Consultants Austin, Texas Warren Hill, MD East Valley Ophthalmology Mesa, Arizona Reay Brown, MD, presented on cataract sur- gery for angle closure glaucoma. He referenced the 2009 landmark glaucoma study showing that cataract surgery lowers IOP in open angle glaucoma. 1 The key insight, he said, was to stratify by preoperative IOP. This inspired Dr. Brown to look at angle closure. It makes sense that cataract surgery is effective in angle clo- sure. Cataract surgery opens the angle to almost a normal depth. Dr. Brown went on to share several cases. The first was a woman with a clear lens who had multiple laser treatments and closed angles for 6 years. She had more cupping in the eye with higher pressure, and it was clear she was getting worse despite maximal treatment. The choices in 2008 were either a trabeculectomy or tube shunt. Dr. Brown thought cataract surgery would be a better choice, but he called it a "rad- ical decision" because she had a clear lens. With 14 years of follow-up, "it's like she doesn't have glaucoma," he said. Dr. Brown wrote this case up with several others in a study. 2 Clear lens extraction showed greater efficacy and was more cost effective than laser peripheral iridectomy and should be an option for first-line treatment. Dr. Brown also brought up the issue of toric IOLs and premium lenses in glaucoma. Even glaucoma patients having cataract surgery want the best possible outcome. He concluded by saying that phaco is effective in glaucoma treat- ment in angle closure at all stages. Steven Dell, MD, presented on late laser vi- sion correction (LVC) enhancements. Surgeons are accustomed to operating on Baby Boomers, but a lot of Generation X patients are starting to appear in the office. Generation X are presby- opic or becoming so, and they grew up with soft contact lenses, some had RK, many had LVC in their 20s, they have a high desire for spectacle independence, and many have lens changes or an outright cataract. IOL calculations are advancing but doing them in the post-LVC patient is still tough, Dr. Dell said. Residual refractive error is a major ASCRS Lindstrom Symposium covers topics in cataract, refractive, cornea, glaucoma, and industry relations T he Richard L. Lindstrom, MD, Lecture this year was given by Warren Hill, MD, on the topic of "Accuracy for IOL power selection ... Are we there yet?" The lecture is part of the Lindstrom Symposium and took place on April 24 at the 2022 ASCRS Annual Meeting Cataract surgery is a growth industry, but one of the problems is it has a limited capacity, Dr. Hill said. How can we be more efficient? Dr. Hill said avoiding complications is the overall goal, and an unanticipated refractive outcome is the most common complication of routine cataract surgery. He went on to discuss IOL power selection, noting that anterior segment surgeons are being judged by patients and peers by refractive outcomes. In terms of accuracy standards, Dr. Hill questioned whether what's most common should be good enough. A significant part of the accuracy of modern theoretical formulas de- pends on the correct estimation of the effective lens position before surgery. Is there another way we can do this? Dr. Hill said this might be a case for the develop- ment and use of artificial intelligence. Artifi- cial intelligence does not limit possibilities to situations that are already understood. It's able to make the best of what's available, bypassing the limitations of physical models. It's also well suited to real-world problems where ideal mod- els are not available. This has incredible sensi- tivity for identifying and unraveling complex, non-linear relationships, Dr. Hill said, and it's free of calculation bias. He also discussed pat- tern recognition with artificial intelligence. Why shouldn't this be used for IOL power? Artificial intelligence allows for the use of a tool that anticipates the accuracy of the calculation. Ophthalmology is experiencing a conver- gence of technologies for IOL power selection accuracy, Dr. Hill said, noting ray tracing, ad- vanced vergence formulas, artificial intelligence, and intraoperative aberrometry. The method with the greatest sensitivity and flexibility will give the greatest accuracy as technology advances, he said. continued on page 40 2022 ASCRS ANNUAL MEETING RECAP ASCRS NEWS

• Cover