Eyeworld

EW MEETING REPORTER 58 May 2014 photocoagulation and triamci- nolone with laser photocoagulation. Compared with laser photoco- agulation, not only do the DRCR.net findings suggest the superiority of anti-VEGF treatment over the proce- dure, but potentially highlight the procedure's essentially destructive nature. One controversy that remains in terms of anti-VEGF therapy is choosing the best agent. Each one, said Mineo Kondo, MD, Japan, has a different target, affinity and half- life. However, at least for Pravin U. Dugal, MD, U.S., the most signifi- cant distinguishing factor is systemic safety. Given the numerous factors to control and the large population sizes required to produce reliable, definitive statistical data, Dr. Dugal considered how ophthalmologists can make safety decisions without such data. He recommended narrowing it down to two questions: What do we look for? Who do we look at? Because anti-VEGF treatment affects systemic vasoconstriction (as an indirect consequence of in- hibiting vasodilation), Dr. Dugan recommended looking for arterial thromboembolic events. Meanwhile, the most vulnerable patient popula- tion is patients 85 years old and above. He supported these recom- mendations with results from ANCHOR, HARBOR, and MARINA, among others. "Cataract from Hell to Heaven" The "Cataract from Hell to Heaven" session kicked off Cataract Subspe- cialty Day, which took place at the Imperial Hotel. The session focused on cataract surgery in compromised patients, including those with black or white cataracts. Topics also addressed were refractive lens exchanges, multifocal IOLs, toric multifocal IOLs, and managing un- happy patients after multifocal IOLs. The session was chaired by Ahmed Elmassry, MD, Egypt, Hussein Ali Hussein, MD, Egypt, Daijiro Kurosaka, MD, Japan, and David Chang, MD, U.S. Dr. Elmassry dis- cussed "Cataract in compromised cornea." He offered pearls when dealing with these types of cases. First, you need to consider a pre- operative evaluation, Dr. Elmassry said. This requires having documen- tation of the pathology of the cornea, specular microscopy for patients with endothelial disease, and systemic disease evaluation. It also requires that a surgeon know the pachymetry as well as corneal biomechanical properties. When dealing with cataracts in a compromised cornea, the surgeon must explain the situation preopera- tively to the patient. This includes discussing the risks and why this type of patient has these risks. A surgeon dealing with a cataract in a compromised cornea must specifically consider the operative procedure. Ophthalmic viscoelastic devices (OVDs) are mandatory in corneal epithelial pro- tection, Dr. Elmassry said. You also have to consider other conditions a patient may have, like dry eye, if the cornea is herpetic, and any endothelial diseases. For patients with endothelial disease, these cases should attract the most attention, Dr. Elmassry said. It is important to explain and document the risks involved for both patients and family members. Especially for those with Fuchs' endothelial dystrophy, there are four ways for protection: soft shell technique, small air bubble on the endothelium, viscodissection, and minimum phaco power. In all com- promised corneas, the endothelial count should not be less than 700 cell/mm 3 and corneal thickness not less than 630 µm. Alaa Elzawawi, MD, Egypt, discussed black and white cataracts, which can pose their own set of challenges. For the black cataract, challenges include incisional burn, shallow AC, a compromised en- dothelium, poor pupillary dilation, difficult anterior rhexis, a dense nucleus, leathery, cohesive, or tenacious fibers, posterior capsule rupture, loss of nuclear fragments, iris trauma, and prolonged postoper- ative inflammation. Dr. Elzawawi usually uses topical anesthesia in these patients, but if complications are expected, peribul- bar can be effective. When dealing with these challenges, he said, it is important to be patient and take your time. Challenges with a white cataract were also highlighted. These in- cluded the anterior capsulorhexis, a mobile small nucleus, and late capsular bag contraction. Dr. Elzawawi discussed how to do a continuous curvilinear capsu- lorhexis (CCC) in a white cataract and the technique used. He said to initiate a central tear, aspirate any milky cortex, inject more viscoelas- tic, do the rhexis in a spiral manner and enlarge as necessary; a complete small rhexis is better than a wide one that extends to the equator. George Beiko, MD, Canada, discussed "Successful strategies for toric multifocal IOLs." He high- lighted the options available to patients, including traditional monofocal IOLs, presbyopic correct- ing IOLs (both multifocal and ac- commodating), and toric IOLs. Newer IOL choices can expand the range of vision; however, Dr. Beiko stressed that there is no perfect lens available. "We don't have a perfect solution, but we do have good com- promises, and surgeons should be able to discuss all these options with patients," he said. Complications in refractive surgery Five presentations went into detail on issues such as endothelial safety in phakic IOL implantation, infec- tious keratitis after refractive surgery, interface complications in lamellar refractive surgery, management of the dissatisfied multifocal IOL patient, and prevention of ectasia in laser refractive surgery. Terrence O'Brien, MD, U.S., discussed infectious keratitis after refractive surgery. The rare but dev- astating occurrence of infection with refractive surgery is something that everyone needs to pay attention to, he said. Infection after LASIK is gen- erally rare, but rates are estimated to be around 1 in 5,000 to 1 in 10,000. The key is prevention, Dr. O'Brien said. It is important to treat LASIK as an ophthalmic surgical procedure, not as a "non-surgical treatment." He said to use common sense and be sure to use a new sterile Reporting live from the 2014 World Ophthalmology Congress, Tokyo Supported by Carl Zeiss Meditec AG

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