Eyeworld

Sponsored by Reporting from the 2016 Combined Ophthalmic Symposium (COS), August 26–28, 2016, Austin, Texas EW MEETING REPORTER 132 Editors' note: Dr. Bafna has no related financial interests. Dr. Dhaliwal has financial interests with Abbott Medical Optics, Avedro (Waltham, Massa- chusetts), and NovaBay (Emeryville, California). Topography tips Mitchell Weikert, MD, Houston, shared topography tips with attend- ees. First, he said that curvature is easier to measure with Placido rings, which can measure the reflection of those rings off the cornea. If we try to measure curvature with elevation, like with Scheimpflug or OCT, he said, we're taking an indirect mea- surement. Second, Dr. Weikert said that ax- ial maps equal the average, whereas tangential maps often give a truer picture of corneal curvature. Difference in maps can help compare changes over time, he said, and pachymetry maps are better than ultrasound because you get thickness over the entire cornea and know the center is the center. Next, Dr. Weikert said that cor- neal power serves two roles in IOL calculations, with the first being to help figure out the overall refractive power of the IOL and the second being to help calculate the effective lens position. Dr. Weikert said not to ignore the posterior cornea. As people age, the anterior corneal steep meridian goes from being vertically orient- ed to horizontally oriented, and accurate astigmatism measurement is necessary to maximize toric IOL outcomes. The next tip was that artifacts may lead to misinterpretation. Dr. Weikert warned the audience that ectasia may show up on the back of the cornea first. Beware of against-the-rule (ATR) astigmatism in the young, he said. The younger patients are, the more you worry about their development of ectasia. Finally, he said that there is no single device to serve all needs. EW Editors' note: Dr. Weikert has financial interests with Ziemer (Port, Switzerland). coherence tomography postopera- tively, rebubbling if edges are mov- ing centrally. Another tip Dr. Fram provided was to use older donor tissue be- cause it is easier to unfold compared to tissue from a younger donor. Editors' note: Dr. Al-Mohtaseb has no financial interests related to her com- ments. Dr. Fram has financial interests with Abbott Medical Optics, Accu- tome (Malvern, Pennsylvania), Alcon, Allergan, Bausch + Lomb, Bio-Tissue (Doral, Florida), and Shire (Lexington, Massachusetts). New in 2016 Shamik Bafna, MD, Cleveland, discussed MKO Melt (Imprimis Phar- maceuticals), which helps perform cataract surgery without an IV. In looking at the overall patient experience, Dr. Bafna said that IV placement is sometimes worse than the cataract surgery itself for certain patients. There are a number of chal- lenges with an IV approach includ- ing accessibility to veins, personnel required to set up and take down the IV pre- and postoperatively, costs associated with IV supplies, patient fear of anticipated IV, and pain asso- ciated with the IV. Transitioning to MKO Melt could be challenging and could take some getting used to by surgeons, so Dr. Bafna recommended continuing to place the IV on all patients and then transitioning gradually. Deepinder Dhaliwal, MD, Pittsburgh, offered her "secrets for success" in the office and OR. In order to achieve success, Dr. Dhaliwal aims to efficiently take care of patients, to make the correct diagnosis quickly, to avoid complica- tions in surgery, and to continually improve by trying new techniques. She added that it's important to have fun. One of Dr. Dhaliwal's key tips in talking to patients prior to surgery is to ask directed questions, particularly to dry eye patients. She said to ask for specific things that are bothering the patient and if there is anything that helps improve their symptoms. DMEK vs. DSEK: The debate continues Two presentations during a cornea controversies session focused on Descemet's stripping endothelial keratoplasty (DSEK) and the slightly newer method Descemet's mem- brane endothelial keratoplasty (DMEK). "Who wins the gold? Which one is better? Is it worth learning the tap dance to do DMEK, or more ap- propriately, is there one that's better than the next?" Zaina Al-Mohtaseb, MD, Houston, asked. Dr. Al-Mohtaseb presented several studies that compared DSEK and DMEK. Based on the literature, in terms of visual outcomes, visual rehabilitation, lower graft rejection rates, and patient preference, DMEK wins. DSEK, however, has an easier surgical technique, is less prone to graft dislocation, and is preferable in eyes with comorbid conditions. Both techniques had similar endothelial cell loss. Dr. Al-Mohtaseb said there will be situations where DMEK might be better for the patient and others where DSEK is preferable. "I think the point of 'do we have to move forward with giving up one technique for another' is just not true," Nicole Fram, MD, Los Angeles, said. "DSEK is still going to have a place in your endothelial keratoplasty armamentarium." Dr. Fram offered several DMEK pearls to make the technically challenging procedure more reliable. One of these included making the descemetorhexis larger than the donor graft by 0.5 mm. She also rec- ommended practicing with the pe- ripheral donor tissue in the Straiko Modified Jones Tube (Gunther Weiss Scientific, Portland, Oregon) prior to inserting the actual graft. This, she said, can help you understand the fluidics before performing the real deal. Other pearls include strategic shallowing of the anterior chamber upon insertion and unfolding of the graft; consider using 20% SF6 instead of air, especially if the case is a combined surgery; and monitor the edges of the graft with optical September 2016

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