Eyeworld

World view Current debates in ophthalmic surgery T his month's feature is "Controversies in ophthalmology." The topics select- ed are among the most contentious in ophthalmology and include the use of intracameral antibiotics, same-day bilateral cataract surgery, the pros and cons of SMILE vs. LASIK, and whether toric IOLs or LRIs are preferred for the correction of pre-existing astigmatism. It appears that the major concern from surgeons on the use of intracameral antibiotics is the lack of an FDA-approved commercial prepa- ration in the U.S., as opposed to the availability of cefuroxime in Europe. The use of intravitreal antibiotics either via the transzonular or pars plana route is controversial and has been advocated in the U.S. by some surgeons as "dropless" cataract surgery. The cost of topical drops is surprisingly much more expensive in the U.S. than in countries like Australia where this is not a major issue in cataract surgery. Although the risk of administering intravitreal antibiotics appears to be small, the thought of encountering an additional risk in an otherwise uncomplicated case of cataract surgery is daunting. Next, we hear how advocates for immediately sequential bilateral cata- ract surgery make a strong case for the cost benefits and efficiency of this sur- gery. There is no doubt that patients would find it attractive to have cataract surgery performed on both eyes on a single occasion and that the additional risk is minimal if the precautions are closely followed. Although the risk of postoperative bilateral endophthalmitis is extremely unlikely, there is always an element of uncertainty with every surgical procedure. Immediately se- quential bilateral cataract surgery is infrequently performed in Australia and the Asia-Pacific region, but the conversation has begun, and I suspect the practice will be considered more often in the future. Personally, my concern is less with the low risk of unexpected complications but rather unexpected refractive outcomes. The third article shows how the uptake of SMILE has been significant in the Asia-Pacific region, and some of the most experienced users present their thoughts on the procedure. There is no doubt that SMILE is extremely effec- tive, particularly with high myopia, with less risk of dry eye associated with LASIK. Nevertheless, there can be issues related to surgical technique, and surface ablation remains an attractive alternative for low levels of myopia. Not being able to correct astigmatism is a limitation of SMILE that may be addressed in the future. In the final article, surgeons express their preference either for toric IOLs or limbal relaxing incisions to correct pre-existing astigmatism. The con- sensus appears that limbal relaxing incisions are most effective for levels of astigmatism less than 1.25 D. On this topic, however, I have a strong person- al preference for toric IOLs. Published data indicates that toric IOLs are more predictable, and every incision disrupts the integrity of the corneal surface. In older patients, LRIs are often associated with irritation requiring lubricants and in Australia and the Asia-Pacific region have largely been replaced by toric IOLs. As yet, there is no evidence that femto-based incisions are more effective than manual incisions, and both are limited by predictability and long-term stability. My experience is that toric IOLs in the range of 1 D are very predictable in the range of astigmatism from 0.50 to 1.0 D. My under- standing is that multifocal toric IOLs and low powered dioptric toric IOLs are not yet available in the U.S., but I suspect that when these are FDA approved, the use of limbal relaxing incisions will decline. EW Graham Barrett, MD International Editorial Board member The official publication of the American Society of Cataract & Refractive Surgery A S C R S June 2016 Volume 21 • No. 6 Publisher Donald R. Long don@eyeworld.org Editorial Editor Amy Goldenberg amy@eyeworld.org Managing Editor Stacy Jablonski stacy@eyeworld.org Senior Staff Writer/Digital Editor Ellen Stodola ellen@eyeworld.org Staff Writer Liz Hillman liz@eyeworld.org Production Graphic Designer Julio Guerrero julio@eyeworld.org Graphic Design Assistant Susan Steury susan@eyeworld.org Production Manager Cathy Stern cathy@eyeworld.org Production Assistant Carly Peterson carly@eyeworld.org Contributing Writers Stefanie Petrou Binder, MD Germany Vanessa Caceres Bradenton, Florida Michelle Dalton Reading, Pennsylvania Rich Daly Arlington, Virginia Lauren Lipuma Washington, D.C. 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