EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/511377
87 EW MEETING REPORTER Panelists said not to ignore EBMD as patients continually de- mand crisper postop vision. "We're paying attention to this more, as it can affect cataract outcomes," Dr. Holland said. Topography can also be beneficial in helping to diagnose EBMD preoperatively, panelists said. Fifty-seven percent of the audience said they would treat the sample EBMD case with phototherapeutic keratectomy, while another 34% said they would use lubrication and hypertonic saline. Other treatment options given were anterior stromal puncture and ignoring the EBMD. Like EBMD, MGD is something that clinicians need to monitor more frequently prior to surgery, panelists said. "We have to change our pattern of examining patients," said Thomas John, MD, Tinley Park, Ill. Instead of examining the cornea first, he believes physicians should first examine the lid margin and tear meniscus to check for ocular surface issues like MGD, and then perform the cornea exam. Of the treatment options given, 58% of the audience said they would recommend the use of omega-3 supplements and artificial tears and demonstrate lid hygiene. Another 31% would use topical azithromy- cin and/or oral doxycycline. Other treatment options given were ther- mal pulsation therapy and intense pulsed light therapy. Cataract dilemmas dissected Should cataract surgeons use intraca- meral antibiotics? Are generic drops as safe as brand-name drops? Which intracameral is best? Experienced surgeons tackled these and other is- sues in the "Cataract Dilemmas and Controversies" symposium. When it comes to intracameral antibiotics, surgeons actually face 2 dilemmas—whether to adopt intra- cameral use and which agent is best. "This is quite a disruptive topic in industry and ophthalmology, and it's something a little out of the box because it breaks a lot of conven- tions that we're used to," said Rob- ert J. Weinstock, MD, Largo, Fla. Dr. Weinstock said that he pre- fers to use intracameral antibiotics rather than topical because they are cheaper, save time, and eliminate the issue of compliance. "One of the biggest things that hurts us in cataract surgery is that we can't control whether the patient is getting the drops or not," he said. "This puts us back in control." Kent Stiverson, MD, Lakewood, Colo., debated the pros and cons of each of the available intracamer- als—vancomycin, cefuroxime, and moxifloxacin. Vancomycin kills Staphylococcus and Streptococcus, the main causes of infection, including methicillin-re- sistant Staphylococcus aureus (MRSA), but it only kills gram-positives, so it has a narrower spectrum than other drugs. It persists in the eye for a long time at a good concentration even if the capsule breaks, but it is a slow killer because it inhibits cell wall synthesis. Cefuroxime also inhibits cell wall synthesis, so it is a slow killer, but its concentration declines rapid- ly. It has a broad spectrum but may not be effective against the most common cause of endophthalmitis, coagulase-negative Staphylococcus. Both vancomycin and cefuroxime must be compounded by a pharma- cy. Moxifloxacin directly inhibits DNA synthesis, so its effectiveness is concentration-dependent. It is a broad-spectrum fast killer that requires no compounding and provides good coverage for gram negatives, but it is expensive, Dr. Stiverson said. In addition to the variability between each antibiotic, physicians face a larger ethical dilemma when choosing a drug because of the issue of emerging resistance. "Our views on how important it is to keep vancomycin effective for everyone versus seeing one of our patients go blind are quite relevant," Dr. Stiverson said. "We have to weigh what matters most to us. Some of us do same-day bilateral surgery, so we must use an intracam- eral. Some of us may have to address MRSA in the community. "I use vancomycin in my practice, but if I were starting with intracamerals today, I would use moxifloxacin. Editors' note: The physicians have no financial interests related to their comments. "Pardon the Ophthalmology" presents rapid-fire case At the "Pardon the Ophthalmology: Corneal and External Disease Chal- lenges" symposium, attendees and panelists alike weighed in on how they would handle tricky cases. The symposium followed the format of the popular ESPN sports show "Par- don the Interruption." Ed Holland, MD, Cincinnati, and Terry Kim, MD, Durham, N.C., moderated the symposium. Drs. Holland and Kim presented a variety of challenging cases that involved everything from dry eye to epithelial basement membrane dystrophy (EBMD) to fungal in- fections to corneal scarring. With each case, a few treatment options were given, and attendees used their response devices to weigh in on their preferred choice. Panelists also discussed how they would handle the case, and occasionally, Drs. Holland and Kim would throw panelists a "red flag" to challenge something that was said. Here are a few cases discussed during "Pardon the Ophthalmology." View videos from Monday at 2015 ASCRS•ASOA: EWrePlay.org Megan Mestas, Denver, discusses how to reach out to Millenials and why they're important in the practice. continued on page 88 May 2015 View videos from Tuesday at 2015 ASCRS•ASOA: EWrePlay.org David Chang, MD, Los Altos, Calif., describes a novel device for creating reliable capsulotomies.