Eyeworld

Reporting from the 2016 ASCRS•ASOA Symposium & Congress, May 6–10, 2016 New Orleans Sponsored by EW MEETING REPORTER 82 June 2016 of patients, in patients with more advanced disease." If trabecular micro-bypass de- vices like iStent are the (relatively) new thing, then endoscopic cyclo- photocoagulation (ECP) is certainly an old technique. First developed by Martin Uram, MD, Little Silver, New Jersey, in 1992, the technique uses an intraocular laser endoscope to shrink part of the ciliary body epi- thelium, reducing the production of aqueous humor. Is it still relevant? Robert Noecker, MD, Fairfield, Connecticut, thinks so. Dr. Noecker highlighted how ECP can be used in conjunction with cataract surgery, with other glaucoma procedures at the time of cataract surgery, as a re- placement medical therapy, in eyes with previous outflow procedures, eyes at risk for hypotony, eyes with conjunctival or scleral issues, or in plateau iris cases. Editors' note: Dr. Vold has financial interests with Glaukos. Dr. Varma has financial interests with Abbott Medical Optics (Abbott Park, Illinois), Alcon, Allergan, Labtician (Ontario, Canada), and New World Medical (Rancho Cucamonga, California). Dr. Noecker has financial interests with Beaver-Visitec International (Waltham, Massachusetts). Charles D. Kelman Innovator's Lecture discusses astigmatism correction and the roots of creativity Curiosity, inspiration, and per- sistence. These are the 3 things that Graham Barrett, MD, Perth, Austra- lia, thinks are the main ingredients that underlie a person's creativity. It is creativity that underlies inno- vation, Dr. Barrett said, giving the 2016 Charles D. Kelman Innovator's Lecture. Dr. Barrett is a clinician who more than meets the definition of an innovator who has advanced ophthalmology. In his lecture "Searching for Symmetry: Reducing Astigmatism at the Time of Cataract Surgery," Dr. Barrett brought the audience back to the roots of his interest in astigmatism. added that the surgeons themselves have to believe in the product. From there, talking about it with the patient—in educational meetings, brochures, or DVDs—is important as well. Dr. Vold recom- mended physicians speak of the iStent as a device that could benefit patients with minimal downsides while also preserving the conjuncti- va for filtration surgery if needed in the future. To achieve success with the iStent, placement is key. Dr. Vold advised audience members to make sure the tip of the inserter is up while taking it out of the packag- ing to avoid dislocating the stent from the get-go. He also said that viscoelastic can help facilitate better insertion and recommended that the stent be placed parallel to the corneal wound. Knowing the patient's anatomy can help avoid stent misplacement, but for difficult angles, such as narrow angles, Dr. Vold said removal of a cataract might be helpful. He also recommended looking "over the hill" or using a "corneal wedge" technique in difficult angle cases. Devesh Varma, MD, Toronto, who has 6 years of experience with the iStent, talked specifically about targeting the implant for optimal outflow. He said physicians should first get comfortable with implant- ing the device in Schlemm's canal and then focus on targeting, which is when the stent is strategically placed near a collector channel that is near 1 of the major episcleral veins. To target optimally, Dr. Varma said the eye should be inflated— overinflated even—with lidocaine or balanced salt solution, to drive aque- ous into the veins to identify where to place the stent. He will mark that location with ink as a general guide. After placement of the iStent, he said the physician can check the effect by seeing if the vein blanches with increased aqueous flow. "That's, for me, some proof on the table that I've hit the right target," he said. "I've found with target implantation, I'm getting much more pressure lowering, and I'm able to do it in a wider array layers of the cornea are developed. The development of endothelial ker- atoplasty procedures promises lower rates of rejection, less complications, better vision, and enhanced graft survival rates, he said. But recent registry studies show the impact of the learning curve for these more surgically challenging procedures. Dr. Tan said that DMEK, as a surgical innovation, epitomizes the current distillation of our ability to replace the corneal endothelium, but the surgery needs to evolve, with improvements in surgical techniques or instrumentation, before the tip- ping point for widespread adoption can be achieved. Editors' note: Dr. Tan has financial interests with Alcon, Allergan, Bausch + Lomb (Bridgewater, New Jersey), Carl Zeiss Meditec (Jena, Germany), and Santen (Osaka, Japan). Optimizing the many MIGS options in practice It's relatively common for there to be patient compliance issues even if patients are only on 1 glaucoma medication. Add other medications on top of that and adherence to medical therapies for glaucoma management drops even more. Still, the patient's disease might not be advanced enough to merit a trabe- culectomy or tube shunt. The advent of multiple micro- invasive glaucoma surgery (MIGS) options has ophthalmologists excit- ed as they can be used to fill this gap for the mild to moderate glaucoma patient who has compliance issues or who is on 3 or 4 drops with IOP that needs further control. Long-term clinical data on the iStent (Glaukos, Laguna Hills, California), the only MIGS implant currently approved by the FDA for use in the United States, continues to come in, but what about incor- porating it into practice? Steven Vold, MD, Fayetteville, Arkansas, led the symposium sponsored by the ASCRS Glaucoma Clinical Commit- tee, speaking on this topic. First and foremost, he said communication and education are critical to incor- porating iStent into practice, but he

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