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81 July 2016 EW MEETING REPORTER residents. But there are a number of other factors to consider. The sur- geon needs to consider patient age, life expectancy, and comorbidities, as well as the type of glaucoma, the stage of glaucoma, and if it's con- trolled or stable. Dr. Prata offered his general tips for choosing when to use phaco or a combined approach for treatment. He first highlighted closed angle glaucoma. If the patient has this with the indication of a cataract, and it's controlled and stable, you can use phaco, he said. If the disease is uncontrolled or progressive, phaco can likely still be used. However, if it's advanced disease and a poor angle, the patient has no support, Dr. Prata said. Phaco does not bring down the pressure, so you need a combined surgery. Meanwhile, indications may be different for patients with open angle glaucoma. If the glaucoma is controlled and stable and is a mild to moderate stage of the disease, phaco alone can be used. But if there's an unexpected event in controlled patients, you may need a combined procedure. If it's advanced disease, many of the patients might have decompensation, so he prefers the combined option, he said. If the open angle glaucoma is not con- trolled, then a combined approach should be used. In most cases of closed angle glaucoma, selecting phaco will get it right, except in some serious cases, Dr. Prata said. These patients are very few, he added, and most glau- coma patients in Brazil have open angle glaucoma. For open angle glaucoma, Dr. Prata stressed that phaco does not have a positive impact on con- trolling this overall. Phaco has a negative impact on almost 40% of these patients, he said. Dr. Prata also stressed the importance of a careful preoperative workup. EW Editors' note: Dr. Prata's presentation was reported on from a translation from Portuguese to English. on the specifics of herpes simplex. This affects many individuals, she said. The infection takes place after contact with a lesion, saliva, tears, or secretion. The primary infection may manifest either around the eyes or the mouth, she added. Recurrence of herpes simplex is multifactorial, Dr. Rezende Bisol said. It may be tied to factors like emotional stress, hormone changes, immunosuppressants, trauma, and even UV exposure. Recurrence may be a problem after excimer laser use or after PRK. Factors in recurrence following excimer laser treatment include ep- ithelial debridement, stress, postop corticosteroid use, the pathogenic- ity of the virus, and spontaneous recurrence. This virus is still one of the main causes of corneal opacity, Dr. Rezende Bisol said. There are 50,000 new and recurrent cases per year in the U.S., and about 50% of cases need optical correction. Antiviral prophylaxis can reduce the risk of relapse by 50%, she said. The excimer laser can still be used for patients with a history of herpes simplex if physicians give them proper antiviral prophylaxis, she added. Editors' note: Dr. Rezende Bisol's presentation was reported on from a translation from Portuguese to English. Coexistence of cataracts and glaucoma Tiago Prata, MD, São Paulo, Brazil, presented on surgical indications of patients with cataract and glaucoma. This is a very controversial top- ic, he said. The correlation between cataract and glaucoma dates back to the 1990s when the focus was on reduction of cataracts while still maintaining quality of life. Most studies were from cataract groups focusing on reduction of pressure in the situation of glaucoma, Dr. Prata said. In his opinion, one problem in the controversy comes from general- ization, especially when there is no reference to the type of glaucoma. There is also the mistake of trying to set guidelines and static rules for However, there are many people who doubt the femtosecond laser. There are arguments that data is limited, that the technology is being pushed by marketing, and that there are specific risks that come with the femto laser. There are ethical and cost questions as well. There are some important points in the femto debate, Dr. Ahmed said, but we still have to be careful when we make claims that the technology is better. We have to be ethical as physicians and sur- geons and do the right thing when presenting it to patients, he added, because there are still a lot of ques- tions to be discussed on this topic. Editors' note: Dr. Centurion's presen- tation was reported on from a trans- lation from Portuguese to English. Dr. Bautista's presentation was reported on from his slides, as his presentation was in Spanish. Challenges, limitations, and controversies Topics highlighted in a session on challenges, limitations, and contro- versies included simulation-based planning in refractive surgery, LASIK vs. ICL in certain circumstances, limitations in refractive surgery, her- petic keratitis and excimer laser, and correction of high refractive errors. Renata Rezende Bisol, MD, Rio de Janeiro, spoke about her- petic keratitis, providing details when combined with premium lenses, he said. The femtosecond laser has a high reproducibility of the surgical technique and makes astigmatism less of a concern, Dr. Centurion said. Dr. Bautista focused on the fem- tosecond laser for complex cataract surgery, but he also stressed where the femtosecond laser is best utilized in cataract surgery. It acts on 3 different phases in cataract surgery: capsulotomy, fragmentation of the nucleus, and corneal incisions. He said that the laser helps provide higher precision in the capsulotomy in terms of size, shape, and centra- tion, as well as better resistance to tearing. Dr. Ahmed presented on femtosecond laser-assisted cataract surgery as a "myth and reality." He highlighted the evidence available about femtosecond laser technology. The ability to use a laser for cata- ract surgery certainly sounds very appealing, he said. The discussion surrounding the femtosecond laser focuses on wheth- er it's safer, more predictable, and more accurate, and it still has to be determined whether this is actually true, he said. Physicians need to un- derstand the benefits and pitfalls. The whole purpose of using the femtosecond laser is for repro- ducibility, effective lens position, refractive accuracy, and reduced ultrasound energy, he added. View videos from BRASCRS 2016: EWrePlay.org Amar Agarwal, MD, discusses a technique for glued scleral fixation of IOLs in children.

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