Eyeworld

77 June 2016 EW MEETING REPORTER Symposium & Congress Clinicians must consider that these approaches are not ideal for all medications, especially prostaglan- dins. They also take a long time to research, and few of these products have undergone peer review, Dr. Lewis said. Editors' note: Dr. Krishna has financial interests with Cloud Nine Development. Dr. Lewis has financial interests with Aerie Pharmaceuticals (Bedminster, New Jersey), Alcon (Fort Worth, Texas), Allergan (Dublin), and various other ophthalmic companies. "Local hero" delivers spotlight Glaucoma Day presentation The highest honored award given at the ASCRS•ASOA Symposium & Congress for glaucoma—the 2016 Stephen A. Obstbaum, MD, Honored Lecturer—was presented to Ronald Fellman, MD, Dallas, during Glau- coma Day. As Douglas Rhee, MD, Cleve- land, started putting together his introductory remarks about Dr. Fellman, he soon found out the glaucoma specialist is somewhat of a "local hero." Dr. Fellman was born in Shreveport, Louisiana, and attended Tulane University in New Orleans for both undergraduate and medical school. His grandfather practiced optometry over on Canal Street. As such, it was only fitting for Dr. Fellman to bring a little bit of New Orleans into his lecture "Canal Surgery: The Big Easy or Po-Boys?" "The problem in glaucoma today is we have so many missing links. There is so much we don't know or understand," Dr. Fellman said. What's more, the growing num- ber of options in glaucoma treat- ment might be a boon for physi- cians but also puts pressure on them to select the right treatment for the right patient. When it comes to canal-based surgery to improve outflow, Dr. Fellman, like others in the field, emphasized that this is best for mild to moderate cases of the disease. Within canal-based surgery there are options to cleave or ablate it, by- pass it, or change its shape. "These options give you the ability to tailor the surgery to the needs of the pa- tient," he said. Depending on a variety of factors, canal surgery could either be considered a microinvasive glaucoma surgery (MIGS)—the Big Easy—or a minimally effective glau- coma surgery (MEGS)—a po-boy. A successful MIGS includes a well-posi- tioned device placed near functional collector channels with favorable wound healing. It could turn into a MEGS if the stent is poorly posi- tioned, if it is placed too far from collector channels, if collector chan- nels are atrophic, or if there is poor wound healing. "The problem is you only need 1 of the [po-boys] to lose, but you need all … of these on the Big Easy side [to win]," he said. Dr. Fellman expounded upon some of these ideas, explaining how even if placement of an implant is perfect within the canal, if it is not near a collector channel or if such a channel is atrophic, it will not result in optimal aqueous outflow. He said collector channels not working is more common in moderate to severe glaucoma cases, which is why proce- dures like this are most effective on the mild to moderate patient. "But what evidence do we have for clinical collector channel dam- age?" he asked. Calling it "crude … but the best we have right now," Dr. Fellman said blanching of episcleral veins when balanced salt solution is added is a "good sign" that collector channels are working after the canal has been opened. Despite a perfect surgery, wound healing can affect outcomes, Dr. Fellman said, providing several pictorial examples where suboptimal wound healing reversed the previous surgical benefits. "How do we modulate wound healing? We're not, that's the prob- lem," he said. Despite some unanswered questions, Dr. Fellman said having surgical alternatives is still a benefit if they are chosen wisely. Editors' note: The physicians have no financial interests related to their comments. Cornea Day highlights controversies and challenging cases The first session of the day focused on challenging cornea cases. Leejee Suh, MD, New York, spoke about infectious keratitis. She presented a case of a 49-year-old female with progressive vision loss, redness, and pain in the right eye. The patient also had myopia, for which she used soft contact lenses. The patient was initially seen elsewhere, and the cornea was cultured, Dr. Suh said. The cultures were negative to date, and tobramy- cin and dexamethasone had been used. However, when the patient presented, she was complaining of worsening eye pain. Is there a role for topical steroids in bacterial keratitis? Dr. Suh said the pros are that they can reduce the severity of stromal melt and scarring. Topical steroids could also inhibit neutro- phil chemotaxis and collagenases. However, there could be a delay in epithelial healing, and the steroids could prolong infections and may allow for fungal infections. The next step for this type of patient, Dr. Suh said, would be to reculture, and do a confocal micros- copy and biopsy. This particular pa- tient was recultured from the cornea and contact lens case. Fortified van- comycin and tobramycin was used, but the patient still complained of severe pain. continued on page 78 View videos from ASCRS•ASOA 2016: EWrePlay.org Rohit Krishna, MD, describes new technology that could enhance patient compliance with glaucoma medication.

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