NOV 2013

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

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62 EW MEETING REPORTER Reporting live from the 2013 European Society of Cataract & Refractive Surgeons Congress, Amsterdam November 2013 Saturday, Oct. 5 Dry eye major issue in refractive surgery Ocular surface disease, particularly dry eye, is a "vicious cycle," with key mechanisms of the disease including inflammation and tear film instability. This cycle is especially problematic in refractive surgery, said Christophe Baudouin, MD, Paris, France. Speaking at the ESCRS/ EuCornea Symposium "Refractive surgery in risky corneas: is it really safe for the patient?" Dr. Baudouin showed an image of the theory of dry eye as a vicious circle, with cell damage, nerve stimulation, and other actions driving issues such as inflammation. "Whatever the cause or whatever the association of dry eye disease with other conditions, it's very important to try to prevent this vicious cycle because whatever you do, even if the LASIK was perfect or [there was] any kind of medication that could cause the dry eye, the patient will have a disease that will be self-stimulated," he said. "It's very easy to enter this cycle. It's very difficult to get out." Dry eye has become a major complication of refractive surgery, not only for its severity, but also its frequency, occurring in about 30% to 35% of refractive procedures, he said. It is vital to educate patients before surgery, including those who are contact lens wearers, about the risk. Using tear substitutes postoperatively also can help, Dr. Baudouin said, as well as pre-screening patients for existing dry eye. Combined crosslinking, excimer laser unproven combination George Kymionis, MD, Crete, Greece, answered the title of his presentation, "Should excimer ablation be combined with crosslinking?" at the ESCRS/EuCornea Symposium with a simple answer: "No." "I think we should not perform routine collagen crosslinking on a LASIK case until we can determine the risks and the benefits, although it's very attractive to offer and charge patients for the extra procedure," he said. There are still too many potential risks of combining crosslinking and refractive surgery, he said. Those risks include haze formation, both anteriorly and posteriorly; the risk of routine UVA exposure to the conjunctiva and corneal stem cells; and the long-term risk to the crystalline lens. Other possible risks include the potential for infection from the increased exposure time and risks to the endothelium. "Crosslinking has several clinical and refractive consequences when combined with refractive surgery," he said. "First of all, we know that the collagen crosslinking has a continuous long-lasting corneal flattening. It also has a significant impact on patient refraction." There are positive reasons for combining the procedures, he said, including the possibility that doing so could prevent ectasia, and crosslinking would compensate for biomechanical destabilization caused by refractive surgery. However, unanswered questions about the combination remain, he said, including: "How can we lift the flap? What about the ablation rate of the crosslinked cornea? Can we predict it?" Ways to avoid pseudophakic cystoid macular edema Prior to cataract surgery, patients should be evaluated for risk of cystoid macular edema (CME), and if patients are found to be at a high risk for it, that risk must be addressed before proceeding with surgery, a surgeon said. In addition, when indicated, preoperative medication and a therapeutic regimen can potentially assist high-risk patients, said Conceição Lobo, MD, Coimbra, Portugal. She spoke at the "Treatment of Macular Edema" Clinical Research Symposia. "If we have a normal patient, it is recommended as a prophylaxis [to prescribe a] topical NSAID during the first month," she said. A topical steroid during the first two weeks with decreasing doses also can be helpful, Dr. Lobo said. Topical NSAIDs can be useful in the inhibition and treatment of CME after cataract surgery, she said. She discussed various treatment possibilities for the prophylaxis or treatment of CME. Even though the approach she outlined could be effective, there remains some controversy about the best prophylaxis or

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