Eyeworld

Reporting from the 2016 World Ophthalmology Congress, February 5–9, Guadalajara, Mexico EW MEETING REPORTER 122 March 2016 Inferior peripheral iridectomy is also important. Dr. Pereira said that a near complete air fill can be left without the risk of pupillary block, although he noted that there is a higher risk in phakic patients. When doing the main incision, he recommended a superior clear corneal tunnel incision of 2.2 to 3.0 mm, and the graft should seal the incision. Meanwhile, the descemeto- rhexis should be the same size or a little bit larger than the graft. Check for the presence of Descemet's membrane (DM) rem- nants, Dr. Pereira advised. After stripping and tissue removal, check for the presence of DM remnants with air and balanced salt solution because these remnants can affect visual acuity and adherence. To implant the DMEK graft, Dr. Pereira said that a number of options may be used, including a custom-made glass injector, a glass pipette, or a modified IOL injector. A double roll facing upward facilitates the graft opening in the correct posi- tion, and when orienting the DMEK graft, correct orientation must be confirmed before unfolding. Surgeons may want to unfold the graft by tapping the outer cor- neal surface, he said. You can unfold with a small air bubble, by rolling on top of the membrane, or by di- rect balanced salt solution injection and/or manipulation. lenses (–4 D or higher) for myopia in the older patient group. Dr. Beiko's favored IOL is a one- piece aspheric, hydrophobic, acrylic, glistening-free, 360-degree square edge one, which he said that several manufacturers make. It's important to think about the tradeoff for patients between better visual quality with a monofocal IOL versus spectacle independence with a multifocal IOL. "You can't do both," he said. When meeting with RLE pa- tients, Dr. Beiko warns them that they may not hit their refractive target and could need a secondary correction—which happens in about 10% to 20% of patients. Preparing patients for what to realistically expect from RLE is crucial, Dr. Velasco Barona said. Like other presenters, he discussed risks associated with RLE, including pos- terior capsule opacification (more common in patients with longer axial lengths), RD (a greater risk in patients with posterior capsule tears, zonular dehiscence, and lattice degeneration), and side effects such as glare and halo. In fact, more than 65% of patients can experience glare and halo, even if they can go about their visual tasks normally, Dr. Velasco Barona said. Options in corneal transplantation A session titled "Dissecting the Cornea" highlighted a number of options for corneal transplantation. Nicolas Cesario Pereira, MD, São Paulo, Brazil, shared some pearls for those trying to "master" DMEK. The procedure has a learning curve, he said. He highlighted several surgical strategies for handling DMEK. First, Dr. Pereira said that obtaining a soft eye is important. In- traoperative posterior pressure is one of the main causes of complicated tissue handling, he said. This makes it more difficult to maintain the air in the anterior chamber. To obtain a soft eye, surgeons may want to use an anti-Trendelenburg position and a manual ocular massage for 2 minutes and Honan balloon for 10 minutes. Then, check the tightness of the eyelid speculum, he said. Centering the DMEK graft is critical, as a large decentration can result in an overlap of DM, which contributes to a higher risk of graft detachment. Centration can be aided by a gentle stroke with the cannula over the corneal surface. When fixating the DMEK graft, Dr. Pereira recommended filling the anterior chamber completely with air at 30 to 40 mm Hg for 20 to 40 minutes. Then, he said, lower the pressure to around 20 mm Hg. With an inferior iridectomy, a near com- plete air fill can be left, he said. In conclusion, Dr. Pereira said that mastering DMEK is "all about having a simplified reproducible technique with low complication rates and being really precise in our technique." Glaucoma in 2016 Remo Susanna Jr., MD, São Pau- lo, Brazil, highlighted peak IOP detection and the importance in glaucoma management. There are a number of ways to assess IOP peak, he said, but some of these tests are not as effective as others. Possible ways to assess this include 24-hour diurnal-nocturnal tension curve, daytime tension curve, single IOP measurements in several days, continuous IOP monitoring, or a wa- ter-drinking test. He thinks that the water-drinking test (WDT) is the best and most practical way to determine View videos from WOC 2016: EWrePlay.org Roberto Bellucci, MD, discusses indications for superficial lamellar keratectomy.

• Cover