Eyeworld

83 August 2016 EW MEETING REPORTER Dr. Solomon had a simple an- swer: "Quality of vision rules." "Splitting light in any way shape or form has to detract from quality of vision," he said. And while no presbyopia solution gives "everything," he said that monovi- sion "provides 'the most' solution with the least downside." Moreover, Dr. Solomon thinks that extended depth of focus IOLs will likely increase the use of mono- vision. "Achieving nirvana" in cataract surgery, making better predictions A symposium co-hosted by the IOL Power Club focused on "achieving nirvana" or making the "perfect prediction" in cataract surgery for better refractive outcomes. Oliver Findl, MD, Vienna, Austria, led the session, speaking about the impact of the capsulor- hexis on the predictability of IOL power. Specifically, Dr. Findl said the "burning question" is whether the femtosecond laser, with the ability to create a more predictable capsulorhexis, is resulting in better outcomes regarding refraction. Dr. Findl went through several studies in which manual capsulor- hexes were compared to those creat- ed with the femtosecond laser. One study had just a small significant dif- ference in favor of the femto-created capsulorhexes, but was that enough to be relevant? he asked. Another study could not read the femtosec- ond laser-created capsulorhexes as being better than manual. His own study, which looked at only manual capsulorhexes in 635 eyes, grouped them into categories as either normal (4.5 to 5.5 mm, 360-degree overlap), eccentric (larger than 5.5 mm), and small (less than 4.5 mm). Tecnis lenses (Abbott Medical Optics, Abbott Park, Illinois) were used most often. Change in capsulorhexis size, IOL axial posi- tion, IOL decentration, and IOL tilt were evaluated. What they found was that there was no significant difference in change in rhexis size among the different capsulorhexis groups, no difference in change in those societies on a specific theme," Dr. Barrett said. This year, the CSCRS sought to provide a comprehensive overview of the wide range of presbyopia solu- tions currently available with the theme "All I Want is Everything." One question that was raised early during the symposium was, given the amount of history we've had with bifocal, trifocal, and the entire range of multifocal presby- opia-correcting IOLs, why hasn't the penetration been better? Around the world, Dr. Solomon said, only 6–9% of implants are presbyopia-correcting IOLs—less than one in 10 patients, he said, are actually receiving them. Bringing that fact further into perspective, he cited projections that show that cataract surgery proce- dures have been growing and will continue to grow well into 2020; meanwhile, despite all the contro- versy surrounding the procedure, femtosecond laser cataract surgery continues to grow—the use of pres- byopia-correcting IOLs on the other hand has remained flat. This is particularly baffling in light of survey data that says in patients aged 55–95 years, 85% were interested in becoming less depen- dent on spectacles at the time of surgery. According to surveys, most surgeons ascribe this low rate to the cost of multifocal IOLs, but Dr. Solomon disagrees. "I don't think it's cost," he said. "I think it's quality of vision." In addition to the difficulty of hitting refractive targets with multifocals on the surgeon's side, Dr. Solomon cited the unpredictability of patient satisfaction with multifo- cal IOLs. Despite this, surgeons have not been ignoring presbyopia; how- ever, rather than multifocal IOLs, Dr. Solomon said that 22.3% of ASCRS cataract surgery patients are targeted for monovision—making monovision two to four times more frequently employed than any other presbyopia treatment. Why should this be the case? Monovision, Dr. Solomon said, "isn't a very sexy topic." that 9% are outside of this range, which he said he doesn't approve of. Additionally, in short eyes, refractive errors are more common. With intraoperative aberrome- try, there is conflicting data in the literature concerning accuracy, he said. Intraoperative alterations of the cornea can cause errors, and this technology does not take the post- operative IOL position into account. With intraoperative OCT measurements, there is significant reduction of the IOL prediction problem, Dr. Findl said. However, it's also technologically demanding and not yet commercially available. "Quality of vision rules" everything presbyopia For the first session of the scientific program of the 29th APACRS annual meeting, experts from APACRS, the American Society of Cataract & Refractive Surgery (ASCRS), and the European Society of Cataract & Refractive Surgeons (ESCRS) came together for the Combined Sym- posium of Cataract and Refractive Societies (CSCRS). The CSCRS—this year chaired by Graham Barrett, MD, Perth, Aus- tralia, Kerry Solomon, MD, Mount Pleasant, South Carolina, and Oliver Findl, MD, Vienna, Austria—is intended "to provide an academic forum for the different regional societies to present the very best of This technology shows a longi- tudinal cut through the entire eye. It's image-based, can potentially screen for macular disease, and can allow surgeons to check for unusual eye geometry. There is also a fixation check that is relevant for keratom- etry. When doing macular screening with swept-source OCT, it can pro- vide good detection of macular holes and CME; however, the technology still has difficulties with geographic atrophy and epiretinal membranes. This is a valuable device to detect macular pathology, but convention- al spectral domain OCT is necessary to refine the presumed diagnosis, Dr. Findl said. The most important impact of swept-source OCT for biometry is the more successful scans, he said. Swept-source OCT for biometry provides imaging of the entire eye. It can screen for macular disease and can predict IOL tilt. In the future, the technology could potentially be used for the cornea back surface, to predict IOL position from the lens shape, and for ray tracing. Moving on to refractive out- comes and measurements, Dr. Findl focused on the use of both intraop- erative aberrometry and intraopera- tive OCT measurements. Refractive outcomes after cataract surgery are within 1 D of refractive error 91% of the time, he said, but this still means continued on page 84 View videos from APACRS 2016: EWrePlay.org Chul Young Choi, MD, discusses a new lenticular imaging system revealing real-time capsular fluctuations.

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