Eyeworld

EW MEETING REPORTER May 2014 59 blade at least for every patient and maybe for each eye if there is doubt. Powder-free gloves can be helpful, especially for the surgeon, as can using a sterile drape with central serration to allow draping of the upper and lower lid separately. Dr. O'Brien said to provide written instructions to patients to avoid wearing eye makeup before LASIK and to ask patients to suspend contact lens wear for at least 48 to 72 hours prior to surgery. If there is an infection suspected, act on it. Samir Melki, MD, U.S., dis- cussed complications that can occur with LASIK, highlighting both intra- operative and postoperative compli- cations. Possible intraoperative complications include flap button- hole, thin flap, free cap, incomplete flap, epi defects, and flap tear, he said. Meanwhile, some of the possi- ble postoperative complications with LASIK are epi-ingrowth, folds, DLK, and ectasia. The topic of management of the dissatisfied multifocal IOL patient was discussed by Gaurav Luthra, MS, India. Dissatisfaction can arise when results of a surgery are different from what the patient expected. Patients may complain of poor reading abil- ity, blurry distance vision, difficulty on computer work, vision not being sharp, and fluctuating vision. This dissatisfaction could stem from unrealistic expectations. Pa- tients might have been oversold on the possibility of not needing glasses following surgery, he said. Addition- ally, they may be unhappy because of unwanted images like halos, ghosting, diplopia, edge glare, or negative or positive dysphotopsia. Patient selection is incredibly important for patients receiving multifocal IOLs. Dr. Luthra said it is key to look for preoperative astigma- tism and aberrations, any coexisting ocular pathology, macular disease, glaucoma, or ocular surface disease. He added that it's important to consider if the patient is myopic or hyperopic. Dr. Luthra highlighted the im- portance of building realistic expec- tations before starting the surgery. This includes discussing time that will be needed to adapt to the multi- focal lens, the possibility for compli- cations, and the plan for the second eye surgery. Never sell total inde- pendence from glasses, he said. If after all precautions before surgery patients are still dissatisfied with their multifocal IOL, he said to identify the most important cause of dissatisfaction. Use clinical exams to determine what the problems is, looking for residual refractive error, residual astigmatism, ocular surface disease, posterior chamber opacifica- tion, IOL decentration, poor neural adaptation, and macular problems. Once the problem is identified, the surgeon can proceed by correcting it in a suitable manner. For dissatisfied multifocal IOL patients, it is important to take spe- cial care when planning the second eye surgery. The most important thing is to try to avoid the same mistakes from the first eye, Dr. Luthra said. Preoperative case selection and counseling are key, he said. "Prevention is always easier than managing." The new and old revisited in AAO symposium Experts discussed "New Surgical Ap- proaches in Ophthalmology" at the American Academy of Ophthalmol- ogy (AAO) symposium, with updates covering both anterior and posterior segment ophthalmic surgery. In "The indications of crosslink- ing in cornea and external diseases," Ana Luisa Hofling-Lima, MD, Brazil, said that the procedure was initially introduced for the treat- ment of corneal ectasia. Dr. Hofling-Lima defined corneal ectasia as biomechanical failure of the cornea, with progres- sive thinning, protrusion, and irregularities in corneal geometry. The condition can be primary, in the setting of keratoconus and pellucid marginal degeneration, or second- ary, typically following refractive surgery. In the past, she said, surgeons were "only spectators" in the devel- opment of keratoconus. Surgeons could do nothing more than wait and see how the condition would progress, ultimately resorting to corneal penetrating grafts. Today, corneal crosslinking pro- vides the opportunity to avoid the development and progression of ker- atoconus. The procedure, she said, is indicated if there is progression of ectasia, or if there is no progression in a patient with very low visual acuity even with glasses, contact lens intolerance, and before or after intrastromal ring segment implantation. Contraindications include corneal scarring and disease, and a history of corneal dystrophy or chemical injury. Studies conducted this year have shown that ectasia can progress after several years—which makes sense, she said, as replacement of corneal keratocytes takes place over 2 to 3 years. Progression can also occur with changes in the posterior, not just the anterior curvature. ta Ca o t mt e F a t at C s n I ru L d n o c e s o e ge rg u S t ct ac ra ar s ts nt e m u r t st as La ry r e s a L y r e s s n I ts t nt e m u ru t st R F H V R W P ) s H S S R K & G Q R I O F X Q G S L W G H S Q H P H F Q D K Q ( , 5 / 6 X F F D V H G L Y R U S Q R L W F D V V R U & R L W D Q L P D [ H S P D O W L O V J Q L U X G V S H F U R ) W Q U R H U S V Q R L V L F Q L I R J Q L G D H U S V H W D U X V Q U R \ O H Y L W D U H S R W V R S H G Q D 6 H Q R K 3 ( < . Q R W J Q L [ H / G 5 H O O L Y V U H [ D ) P R F O R D # W V Q L V Q H K S H W V O L D 0 P R F W V Q L V Q H K S H W V Z Z Z $ 6 8 continued on page 60

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