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EW RESIDENTS 62 December 2015 the use of the suction ring for laser administration and a Sinskey hook to open the corneal incisions follow- ing the use of the femtosecond laser leading to corneal epithelial dam- age at incision sites. At this time, it does not appear that FLACS offers a superior alternative to patients with or without dry eye symptoms in the immediate postoperative period. More studies with longer postoper- ative times are needed to assess if patients return to their preoperative baseline. As access to FLACS increas- es, it will be interesting to see if femtosecond laser-assisted cataract surgery will become the standard method of cataract removal just as manual phacoemulsification re- placed intracapsular or extracapsular cataract extraction. EW References 1. Han KE, et al. Evaluation of dry eye and meibomian gland dysfunction after cataract surgery. Am J Ophthalmol. 2014;157(6): 1144–1150. 2. Schaumberg DA, et al. Prevalence of dry eye syndrome among US women. Am J Ophthalmol. 2003;136(2):318–326. 3. Schaumberg DA, et al. Prevalence of dry eye disease among US men: estimates from the Physicians' Health Studies. Arch Ophthal- mol. 2009;127(6):763–768. 4. Pouyeh B, et al. Impact of ocular surface symptoms on quality of life in a United States veterans affairs population. Am J Ophthalmol. 2012;153(6):1061–1066. 5. Rodriguez AE, et al. Comparison of goblet cell density after femtosecond laser and mechanical microkeratome in LASIK. Invest Ophthalmol Vis Sci. 2007;48(6):2570–2575. Contact information Waxman: waxmane@upmc.edu research has shown a 3- to 6-month recovery time following cataract surgery; and not evaluating the tear break-up time at the slit lamp, which is a common metric used by most ophthalmologists in assessing dry eye. Their use of Keratograph 4 is not widespread among ophthal- mologists at this time. Additionally, although it is unlikely the 1 day of pranoprofen caused any significant ocular surface changes, the PCS group was not subject to this medi- cation preoperatively. Yinhui and colleagues conduct- ed the first study to evaluate FLACS' effect on dry eye following cataract surgery. This study highlights prior knowledge that cataract surgery exacerbates dry eye symptoms, regardless of technique (FLACS versus PCS). Interestingly, patients undergoing PCS performed better in the immediate postoperative period. Despite the short follow-up time, patients in the PCS group fared bet- ter with regard to dry eye symptoms and ocular surface characteristics compared to FLACS. Potential expla- nations for the discrepancy include Review continued from page 61 Third-year residents Anton M. Kolomeyer, MD, PhD, Shilpa M. Kodati, MD, John S. Swogger, DO, Colin J. Prensky, MD, and Benjamin R. Strauss, MD Source: UPMC Eye Center, University of Pittsburgh School of Medicine View the EyeWorld CME and non-CME supplements at: cmesupplements. eyeworld.org supplements. eyeworld.org Modernizing cataract surgery: Navigating success with toric multifocal IOLs Supplement to EyeWorld September 2015 Supported by an educational grant from Abbott Medical Optics by Francis Mah, MD Success with toric and multifocal IOLs The 2014 ASCRS Clinical Survey demonstrated educational gaps regarding toric and multifocal intraocular lenses T he ASCRS Clinical Survey revealed important information regarding members' use of toric and multifocal intraocular lenses (IOLs). 1 This annual survey is conducted to examine the most compelling and con- troversial issues facing ASCRS members. It included 267 data points from 134 questions on key clinical opinions and practice patterns. It surveyed more than 1,500 unique respon- dents. Toric IOLs After implanting a toric intraocular lens (IOL), 33% of respondents believe 10 degrees of postoperative rotational error or more does not significantly affect visual acuity or quality (Figure 1). When members were asked, "How are you aligning the preoperative axis assessed with your diagnostic tools with your intraop- erative axis where you are placing the toric IOL during surgery?" 37% of respondents are not using any instrumentation to guide their alignment marks. Of these, 6% use anatomic landmarks without preoperative marking, and 31% use ink marking at the slit lamp with- out additional instruments. I found this very surprising. They were correcting astigmatism, however, they were not using any instrumen- tation to guide the alignment of toric IOLs. The survey results demonstrated little consensus on how to manage 1.25 D of astigmatism (Figure 2). Nearly 54% chose toric IOLs. continued on page 3 Figure 1. The 2014 ASCRS Clinical Survey asked, "After implanting a toric IOL, how many degrees of postoperative rotational error is acceptable before visual quality and visual acuity are significantly affected? 33% of respondents believe >10 degrees of error does not significantly affect visual quality/acuity 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Less than 5 5 6 to 9 10 Great than 10 Depends U.S. Non-U.S. Overall Supplement to EyeWorld September 2015 Figure 2. The survey asked, "What is your most common procedure to manage astigmatism in a cataract patient with the following levels of cylinder?" Little consensus on how to manage a 1.25 D patient On axis incision 0.75 D 1.25 D 2 D 3 D 42.1% 12.0% 0.9% 0.5% Manual LRI or AK 13.2% 17.1% 3.5% 1.1% Femtosecond laser LRI or AK 7.9% 8.3% 1.6% 1.1% Toric IOL 5.9% 53.9% 89.7% 91.6% Postop laser vision correction 0.9% 1.6% 2.7% 3.6% Glasses or contact lenses 7.1% 5.3% 1.5% 1.8% No special correction needed 22.9% 1.9% 0.1% 0.2% Little consensus on how to manage a 1.25 D patient Supplement to EyeWorld September 2015 Edward J. Holland, MD The X Factors: Three areas that will improve refractive cataract surgery outcomes Supported by unrestricted educational grants from Alcon Laboratories and Omeros Accreditation Statement This activity has been planned and imple- mented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint providership of the American Society of Cataract & Refractive Surgery (ASCRS) and EyeWorld. ASCRS is accredited by the ACCME to provide continuing medical education for physicians. Educational Objectives Ophthalmologists who participate in this activity will: • Distinguish predisposing factors putting patients at higher risk for inflammatory reaction after cataract surgery • Identify the true impact of ocular inflam- mation levels on outcomes in refractive cataract surgery • Identify new agents and acquire strategies to eliminate inflammation and relieve pain by maximizing the penetration of anti- inflammatory agents into target tissues • Assess the clinical impact of various levels of ultrasound energy applied during cataract surgery, and how these differ with complex vs. routine cataract patients • Recognize the amount of reduction in these levels available with laser cataract technol- ogy for specific types of patients Designation Statement The American Society of Cataract & Refractive Surgery designates this enduring materials activity for a maximum of 1.0 AMA PRA Cate- gory 1 Credits. ™ Physicians should claim only credit commensurate with the extent of their participation in the activity. Claiming Credit To claim credit, participants must visit bit.ly/1PhspcC to review content and download the post-activity test and credit claim. All participants must pass the post- activity test with a score of 75% or higher to earn credit. Alternatively, the post-test form included in this supplement may be faxed to the number indicated for credit to be awarded, and a certificate will be mailed within 2 weeks. When viewing online or downloading the material, standard Internet access is required. Adobe Acrobat Reader is needed to view the materials. CME credit is valid through March 31, 2016. CME credit will not be awarded after that date. Notice of Off-Label Use Presentations This activity may include presentations on drugs or devices or uses of drugs or devices that may not have been approved by the Food and Drug Administration (FDA) or have been approved by the FDA for specific uses only. ADA/Special Accommodations ASCRS and EyeWorld fully comply with the legal requirements of the Americans with Disabilities Act (ADA) and the rules and regulations thereof. Any participant in this educational program who requires special accommodations or services should contact Laura Johnson at ljohnson@ascrs.org or 703-591-2220. Financial Interest Disclosures David M. Goldman, MD, has received a retainer, ad hoc fees or other consulting income from and is a member of the speakers bureau of Alcon Laboratories Inc., Allergan, and Bausch + Lomb. He has received a re- tainer, ad hoc fees or other consulting income and has an investment interest in Modernizing Medicine. Dr. Goldman has an investment interest in Ophthotech. Preeya K. Gupta, MD, has received a retainer, ad hoc fees or other consulting income from BioTissue and TearScience. Edward J. Holland, MD, has received a re- tainer, ad hoc fees or other consulting income from and is a member of the speakers bureau of Alcon Laboratories Inc., Bausch + Lomb, Kala Pharmaceuticals, Mati Therapeutics, PRN, RPS, Senju Pharmaceuticals, TearLab, and TearScience. He has received research funding from Alcon Laboratories Inc., Mati Therapeutics, PRN, and Senju Pharmaceuti- cals. Dr. Holland has received travel expense reimbursement from Alcon Laboratories Inc. and Bausch + Lomb. Mitchell A. Jackson, MD, is a member of the speakers bureau of Allergan, Avellino, Bausch + Lomb, Carl Zeiss Meditec, Diopsys, Doctor's Allergy Formula, Marco Ophthalmics, Nicox, Omeros Corporation, Science Based Health, Sucampo Pharmaceuticals, TearLab, and TearScience. He has an investment interest in Ace Vision Group Inc. Staff members Laura Johnson, Beth Marsh, and Erin Schallhorn have no ophthalmic- related financial interests. by Edward J. Holland, MD Experts take aim at threats to optimal results diagnostic accuracy of ocular sur- gery diseases (OSDs) and treatment efficacy?" 62% agreed or strongly agreed that Schirmer testing reliably increases their diagnostic accuracy. Only 13% use advanced tear film diagnostics at the initial point of care. The Schirmer test is more than a century old, and we believe there are newer, better ways to identify dry eye. In response to a question regarding whether they follow the Dry Eye Workshop (DEWS)/Delphi guidelines for treating dry eye and meibomian gland dysfunction, most respondents didn't know or didn't use evidence-based guidelines (Figure 1). Visual outcomes When members were asked how many degrees of postoperative rotational error is acceptable after implantation of toric intraocular lenses (IOLs) before visual quality and visual acuity are significantly affected, nearly a third responded 10 patterns based on responses from more than 1,500 unique respon- dents. It focused on 267 data points related to the most compelling and controversial issues facing ASCRS members and has guided the ASCRS Program Committee on its educa- tional efforts. Dry eye diagnosis and treatment When members were asked, "How much do you believe the following tests can reliably increase your Our panel of experts will concentrate on the 3 factors that physicians can control to enhance refractive cataract surgery outcomes: dry eye diagnosis and treatment, reducing residual error, and elimi- nating or reducing postop inflam- mation. Respondents to the 2014 ASCRS Clinical Survey reported important information about their practices regarding these issues and a range of others. This extensive survey revealed opinions and practice Experts share insights on dry eye diagnosis and treatment, reducing residual error, and eliminating or reducing inflammation after refractive cataract surgery I n this supplement, we will examine the "X factors"—the extra undefinable elements that may lead to the best possible outcomes for your refractive cataract surgery patients, who have high visual expectations from their procedures. " … There is increased awareness of the significance of inflammation and the role it plays in outcomes regarding vision and pain. "

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