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Reporting from Hawaiian Eye 2016, January 16–22, Wailea, Hawaii EW MEETING REPORTER 96 Sponsored by using tears, plugs, lid hygiene, loteprednol, or other steroids. Step 3, Dr. Hovanesian said, is to simulate the enhancement using a contact lens or trial frame. Finally, his fourth step is to choose a procedure, with options including LRI, mini/micro- RK, piggyback, toric IOL rotation, or PRK/LASIK. About 10% of refractive cataract patients will be unhappy, regardless of the lens implant type, Dr. Hovanesian said. A "refractive miss" tops the list of reasons for this unhappiness. There are a variety of tools available to address these pa- tients, he said, but you also have to be able to find the unhappy patients and really try to help them. Editors' note: Dr. Hovanesian has no financial interests related to his presentation. One eye trials There are a number of methods being explored for better control and measurement of IOP. Robert Fechtner, MD, Newark, N.J., dis- cussed the one eye trial for medica- tion and whether this is an effective method. The one eye trial has been used as an efficient solution to assess treatment efficacy for lowering IOP, he said. This involves measuring the pressure in both eyes, treating 1 eye recognized the barriers because there is no real commercially available product. He stressed the importance of embracing intracameral antibiot- ics because infections after cataract surgery do occur. Editors' note: The physicians have no financial interests related to their presentations. IOL challenges Dealing with refractive misses was the topic that John Hovanesian, MD, Laguna Hills, Calif., discussed. The challenge is dealing with the unhappy patients that we don't know about, he said. Most of these patients are usually very satisfied with their vision, even years after surgery. Dr. Hovanesian said this was noted in a study he did, and there was no significant difference between lens types. But what about the small per- cent where something isn't quite right? Dr. Hovanesian went through his steps for dealing with these refractive patients. Step 1, he said, is to address PCO. Treat the patient early before the enhancement; focus posteriorly; use low energy if you have a silicone lens; and do a follow-up exam for refraction, IOP check, and satisfac- tion, he said. The second step is to manage the ocular surface. This includes Audience voters weighed in on how they would handle a crowd- ed anterior chamber. The majority (28%) would use OVD only, with 21% opting for a vitreous tap with a vitrector. Editors' note: The physicians have no financial interests related to their presentations. Endophthalmitis Terrence O'Brien, MD, Palm Beach, Fla., spoke about why he doesn't use intracameral antibiotic injec- tion. Evidence increasingly points to intracameral delivery of antibi- otics at the conclusion of the case as the preferred route of delivery for protection from clinical en- dophthalmitis, Dr. O'Brien said. However, there are several concerns when using intracameral antibiot- ics, he said. These include errors in dilution, contamination, TASS, and the patient having an anaphylaxis/ penicillin allergy. Incidence of TASS can relate to mixing, concentration, or buffering errors. Cystoid macular edema (CME), endothelial cell loss/ toxicity, and retinal toxicity are also potential risks when using intracam- eral antibiotics. The use of preoperative and postoperative topical antibiotics for endophthalmitis prophylaxis is per- vasive in the U.S., Dr. O'Brien said. "Most surgeons are using topical antibiotics, but the use of intraca- meral antibiotics has increased but still is much less than outside the United States," he said. The lack of an approved antibiotic for intracam- eral use is the primary reason for the lesser use, Dr. O'Brien added. Eric Donnenfeld, MD, Rock- ville Centre, N.Y., presented the other side of the topic and told the audience why he uses intracameral antibiotic injection. "We have a problem with topical antibiotics because there is an unmet need with drug delivery," he said. Problems with topical drops include compliance, quality of life, manual dexterity, ocular surface toxicity, penetration into the eye, and cost, he said. The use of intracameral antibiot- ics is an idea whose time has come, he said. However, Dr. Donnenfeld View videos from Hawaiian Eye 2016: EWrePlay.org Kevin Miller, MD, discusses how to approach IOL selection in the cataract patient with capsular compromise. continued on page 98 February 2016

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