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67 EW MEETING REPORTER Ophthalmology (AAO) 2014 annual meeting are minimally invasive. "Because of the extended depth of field, it makes the procedure robust to presbyopia evolution," Dr. Gatinel said. This means that over time, the uncorrected near vision remains constant. "I think as a surgeon, I will always prefer a less invasive proce- dure," he said, adding that implant- ing and centering the inlay is easy and quick. Editors' note: Dr. Gatinel has financial interests with Bausch + Lomb (Bridgewater, N.J.), Hoya Surgical Optics (Tokyo), Nidek (Fremont, Calif.), PhysIOL (Liège, Belgium), and Reichert Ophthalmic Instruments (Buffalo, N.Y.). Opening session focuses on debates in vitreoretinal surgery Retina Subspecialty Day 2014: Reaching New Heights kicked off with a session dedicated to ad- dressing the most pressing issues in vitreoretinal surgery. In "Fact or Fiction: Current and Emerging Vit- rectomy Systems," surgeons debated the advantages and disadvantages of current vitrectomy techniques, in- cluding faster cut rates, small gauge surgery, duty cycle control, endo- scopic vitrectomy, and peristaltic versus venturi pump systems. In the second part of the session, surgeons debated the pros and cons of broader surgical issues, including anterior chamber IOLs versus fixed posterior chamber IOLs, perfluoro-n-octane versus drain- age retinotomy, disposable versus reusable instruments, pars plana vitrectomy with or without scleral buckle, and combination macular and cataract surgery. In the "Late Breaking Develop- ments" session, retinal specialists presented data from several ongoing retrospective and observational stud- ies evaluating the effects of current intravitreal injection therapies. Rahul Khurana, MD, Mountain View, Calif., presented results from the NEWTON Study, which evaluat- ed the effects of intravitreal afliber- cept (Eylea, Regeneron Pharmaceu- ticals, Tarrytown, N.Y.) on cystoid macular edema (CME) associated with central retinal vein occlusions. The study found that switching pa- tients from ranibizumab (Lucentis, Genentech, South San Francisco) or bevacizumab (Avastin, Genentech) to aflibercept increased the time interval where patients were free of CME, which may help to reduce the treatment burden associated with the disease. Editors' note: Dr. Khurana has finan- cial interests with Allergan (Irvine, Calif.), Genentech, and Regeneron. Smoothing out the rough surfaces This year's Cornea Day embraced the theme "Restocking the Toolbox: Concepts and Techniques for the Toughest Jobs." Sessions highlighted topics including inflammatory disorders, cornea controversies, corneal surgery quandaries, and challenging cases. Marian Sue Macsai-Kaplan, MD, Glenview, Ill., discussed a spe- cific case she treated of an 18-year- old ballerina who was diagnosed with limbal stem cell deficiency (LSCD) associated with contact lens wear. Dr. Macsai-Kaplan said this condition is a common problem, although it is not usually as severe as this particular case. "But the rea- son we're not seeing it is we're just not looking for it," she said. In this case, Dr. Macsai-Kaplan proceeded with aggressive treat- ment, starting with punctal plugs, which are typically not used ini- tially. She proceeded with topical cyclosporine, prednisolone acetate, and polysporin/trimethoprim anti- biotics until the defect resolved. In this particular patient, she recom- mended that the patient only use her contacts when performing. Dr. Macsai-Kaplan noted that she had to negotiate with the patient to not wear her contact lenses daily. The take-home message, she said, is to look for late staining in contact lens patients, loss of limbal architecture, whorl-like epitheliopa- thy, and opaque epithelium arising from the limbus with late fluoresce- in staining. Editors' note: Dr. Macsai has no finan- cial interests related to her comments. Clinicians share their top 5 tips The Cornea Day afternoon session kicked off with surgeons offering tips and advice on a number of topics. Reay H. Brown, MD, Atlanta, offered his top 5 pearls for combin- ing glaucoma and cataract surgery. The first MIGS device approved for use in the U.S. is the iStent (Glaukos, Laguna Hills, Calif.). "Cornea and cataract surgeons are just as import- ant to the development of MIGS as glaucoma specialists," he said. MIGS is different from other glaucoma procedures because it is a chance to safely help your cataract patients who have glaucoma, and it is within your skill set, Dr. Brown said. MIGS is a new way of thinking about glaucoma surgery. This ab in- terno incision has minimal trauma and is not destructive by strict defi- nition. It is safe with rapid recovery and effective. "Pick the right patient," Dr. Brown said. MIGS is not a replacement for trabs and tubes. Another pearl was to set proper expectations. The goal is to lower IOP, Dr. Brown said, and to perhaps reduce the number of drops a pa- tient uses. But it is important to be realistic about pressure reduction. "Learn the technique," he said. If you are going to be using new technology, expect challenges. But anyone who can do phaco can put in a MIGS device, Dr. Brown said. Finally, he said that this is only the beginning. There will be new MIGS devices both in the canal and in the suprachoroidal space, he predicted. Juan Batlle, MD, Santo Domingo, Dominican Republic, shared 5 times that you need a fem- tosecond laser. He offered examples and looked at specific cases of when this technology is useful. Types of cases discussed included cataract with prior ICL surgery, small pupils, shallow anterior chambers, white cataracts, and black cataracts. Editors' note: Dr. Brown has financial interests with Ivantis (Irvine, Calif.), Transcend Medical (Menlo Park, Calif.), and Allergan. Dr. Batlle has financial interests with Abbott Medical Optics (Santa Ana, Calif.), Alcon, Bausch + Lomb (Bridgewater, N.J.), STAAR Surgical (Monrovia, Calif.), InnFocus (Miami), OPKO (Miami), and Santen (Osaka, Japan). Pseudoexfoliation not just a Scandinavian disease, experts say Glaucoma Subspecialty Day 2014: Integrating New Technologies and Approaches Into Your Daily Practice kicked off with a discussion of the etiology, diagnosis, and treatment of pseudoexfoliation syndrome. The main theme of the session was that pseudoexfoliation syndrome arises as the result of multiple genetic and environmental factors that are not completely understood. While pseudoexfoliation is traditionally thought of as a Scandinavian disease because it oc- curs at a more frequent rate in that region of the world, Louis Pasquale, MD, Boston, pointed out that Scandinavian heritage is not a risk factor for it. Polymorphisms in the LOXL1 gene that are associated with the development of pseudoexfolia- tion are not specific to Scandinavian populations, he said, and occur naturally in many individuals who never develop the disease. continued on page 68 November 2014