DEC 2013

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

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November 2013 plicit, which [physicians] are required to send in a standardized, structured way, and receive in a standardized, structured way and then incorporate, so you can reconcile these into your records," Dr. Reider explained. "The most important thing you can do today if you haven't done it is to make sure you go home and don't qualify for the penalty because the fix is so easy," said Stephen Kamenetzky, MD, St. Louis, Mo. "One element, the [Physician Quality Reporting System, PQRS], one time, for each doctor in the practice. It would be inexcusable for anybody who's been at this meeting and been at this session to be hit with that penalty because it's so easy to fix." Editors' note: The doctors have no financial interests related to their presentations. Monday, November 18 Learning from mistakes Even in the hands of experts, not all cataract surgeries go as planned, as attendees at a "Spotlight on Cataract Complications" session found out during the second day of the American Academy of Ophthalmology meeting. Session co-chair David F. Chang, MD, said the key is to remain calm. "Don't panic—take a deep breath," he said, adding that even unwelcome events during surgery can result in good visual outcomes. For instance, if there is a break in the anterior capsule, what should you do? With a continuous curvilinear capsulorhexis (CCC) tear or defect and a moderately firm nucleus, 43% of the attendees would proceed slowly with intracap. What Roger Steinert, MD, Irvine, Calif., did was perform a "gentle hydrodissection," he said. The lesson, he said, is to use viscoelastic under the iris before stripping, and to constantly keep OVD in the chamber to prevent shallowing. When there is a wraparound posterior capsule tear, the majority of attendees would opt for placing the IOL in the sulcus (67%), but 21% would perform a limbal vitrectomy in addition to placing the IOL in the sulcus. Stephen S. Lane, MD, Stillwater, Minn., said the first thing a surgeon should do in this type of situation is to use triamcinolone to ensure no vitreous strands are coming forward. (He did warn, however, that if the eye is already filled with OVD, triamcinolone will not be useful.) When the patient is supposed to receive a multifocal lens and there's a posterior capsule defect, "do not put the lens in the bag," Dr. Lane said, but it's not necessary to convert the patient back to a monofocal. "If there's any concern about vitreous coming forward, refill the chamber with OVD to avoid the depressurization that can take place," he said. Almost half the attendees would stop the surgery after a posterior capsule rupture and viscodissect; almost 30% would stop and hydrodissect. More than two-thirds of attendees would hydrodelineate polar cataracts, 41% would opt for a monofocal three-piece, sulcus-fixated lens and CCC capture in cases of posterior capsule rent with a capsular tension ring in the bag. If it's a second eye surgery and there were complications with the first, panelist Bonnie A. Henderson, MD, Boston, said to be wary before starting the second surgery. When a complication does occur, 52% of attendees recommend informing the patient immediately. Editors' note: The physicians have no financial interests related to their presentations. eye. Because "the cataract is the major problem, in mild glaucoma, cataract surgery alone is the way to go," declared James Tsai, MD, Philadelphia, citing several studies that showed cataract surgery can reduce IOP up to 27% in people with pressures between 23 mm Hg and 31 mm Hg. Malik Kahook, MD, Boulder, Colo., argued combining phaco with endocyclophotocoagulation (ECP) would be a better solution to reduce treatment burden. One of his pearls with ECP is to set the laser for 0.25 watts "on continuous mode," and to put OVD in after the cataract surgery. "You want to 'paint' the area to get the best effect with ECP," he said. Phaco and angle surgery— including the iStent (Glaukos, Laguna Hills, Calif.) and the Trabectome (NeoMedix, Tustin, Calif.)—should be the way to go, said Thomas D. Patrianakos, MD, Chicago. For one thing, angle surgery "does not preclude subsequent procedures," and there are no negative effects from them because they preserve the conjunctiva. In the "welterweight" contest, a 67-yearold with 20/60 and an IOP of 31 mm Hg and 29 mm Hg on three glaucoma meds presented. "The first thing you need to do is determine what the target IOP is and how far from it you are," said Ike Ahmed, MD, Toronto. One of his pearls for implanting an iStent is to "avoid superficial placement." That said, 54% of the audience believed a trab was the best procedure for this patient. The "heavyweight" bout involved a EW MEETING REPORTER 66-year-old with 20/50, –2 D, with 24/26 mm Hg. History indicated a previous trab. She now presents with a 20/60 posterior subcapsular cataract and visually significant astigmatism. Surgeons need to consider the potential causes of the refractive error, panelists said. The conservative approach for this patient may be a monofocal lens, but 70% of the audience would implant a toric lens. Editors' note: The physicians have no financial interests related to their presentations. Symposium features latest in keratoplasty advances Exciting new possibilities in keratoplasty include advances in deep anterior lamellar keratoplasty, femtosecond-assisted surgery, and keratoprosthesis, physicians said. At the "Advances in Keratoplasty: Where we are in 2013" symposium, a combined meeting with the Cornea Society, nine physicians gave presentations on advances in keratoplasty procedures, including the Castroviejo Lecture. Woodford S. Van Meter, MD, Lexington, Ky., discussed keratoplasty trends in the U.S. Victor L. Perez, MD, Miami, presented management of failed keratoprosthesis. "Indications for keratoprosthesis … are patient selection, patient selection, patient selection," said Dr. Perez. "You need to decide which patient you really want to do this with." Managing glaucoma and cataract Surgeons have known for years that cataract surgery alone can lower intraocular pressure, but is it a sufficient standalone procedure? That depends, according to a group of presenters during a joint ASCRSAAO session. The collaborative symposium used case scenarios to introduce the "featherweight, welterweight, and heavyweight" debates, said co-chair Douglas Rhee, MD. In the first "fight" a fictitious patient had 20/40 corrected vision, with an IOP of 22 mm Hg in one eye and 24 mm Hg in the contralateral 59 continued on page 60 Scan QR code to go to EWrePlay.org Keith Walter, MD, Winston-Salem, N.C., (right) discusses his technique of femtosecond laser-assisted corneal tattooing for symptomatic relief of iris defects.

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