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Reporting from ASCRS YES ACT, September 24–25, Denver EW MEETING REPORTER 162 October 2016 Complex, unplanned, and advanced cataract surgeries When you're starting out with a complex cataract case, the risk factor for complications is already high. Richard Davidson, MD, Den- ver, provided pearls for preventing "peril" in these already complex cases. A white cataract is probably the most common complex scenario seen by cataract surgeons with the condition making the capsulotomy more difficult. These cases have denser nuclei and more potential for zonular weakness. Preoperatively, Dr. Davidson said biometry is more difficult in white cataract cases, and physicians should check for afferent pupillary defect and other ocular co-mor- bidities. Dr. Davidson reminded attendees that they must document everything and inform patients that their visual acuity may be limited postop due to the fact that the optic nerve and retina were not visible preoperatively. In these cases, Dr. Davidson said most modern phaco machines allow for phacoemulsification of dense, white cataracts, but in some rare cases extracapsular extraction might be safer. At the time of surgery, Dr. Davidson said it is important for the surgical staff to have all the mate- rials that could possibly be needed on hand. These include trypan blue, capsular tension rings, capsular support hooks, suture materials, and different IOL choices. Dr. Davidson said trypan blue should be applied under air or viscoelastic and noted that the dye can lead to decreased elasticity of the lens capsule. The pressure in the anterior chamber should be kept greater than that in the capsular bag with smaller incisions, a cohesive viscoelastic, and use of micro-instru- mentation. "Remember to stay calm; you're in control," Dr. Davidson said, adding that patients are awake and aware of emotions in the room. "Even if it's the worst scenario possi- ble, take a deep breath … and figure out a way to solve the problem." advised attendees to practice using the gonioprism at the end of routine cataract surgeries before removing the viscoelastic. "The more you do that, the more natural it becomes," Dr. Sarkisian said, adding that practice will help you get over the learning curve of patient setup before moving onto an actual MIGS procedure. His tips for successful use of the gonioprism were to avoid blood on the corneal surface, have sufficient tilt of the microscope and the head to allow for an en face view, use a high enough magnification, and make sure you are centered and in focus. Charles Weber, MD, Salt Lake City, provided some pearls for place- ment of the iStent (Glaukos, Laguna Hills, California). He personally plac- es it after cataract surgery, though it can be done before. He enters Schlemm's canal with the stent in- serter at 15 degrees, flattens out, and cannulates. Dr. Weber said when you pick a spot for the stent, you need to commit to it. If you don't, you could create a hemorrhage. Confirmation of proper stent placement includes a blood reflux and balanced salt solution blanching of the blood vessels, but Dr. Weber said this doesn't always occur. Several other MIGS and "al- most MIGS" options were discussed during the session, some of which are currently FDA approved, while others are still coming down the pike. In addition to new MIGS pro- cedures in the future, Dr. Sarkisian said he thinks there will be more combined procedures, as well as sustained-release medications. "It is a fun time to be a glauco- ma specialist for sure," he said. Editors' note: Dr. Sarkisian has finan- cial interests with Alcon, Aeon Astron (Leiden, Netherlands), Beaver-Visitec (Waltham, Massachusetts), Glaukos, InnFocus (Miami), Katena (Denville, New Jersey), Sight Sciences (Menlo Park, California), and New World Medical (Rancho Cucamonga, Califor- nia). Dr. Weber has financial interests with Glaukos and Ocular Therapeutix (Bedford, Massachusetts). Editors' note: Dr. Davidson has finan- cial interest with Carl Zeiss Meditec. Making a difference in government decisions With many changes in Medicare reimbursement being implemented soon and more government regu- lations to come in the near future, Nancey McCann, ASCRS•ASOA director of government relations, highlighted the importance of advocacy and getting involved. She stressed that "you have the power to make a difference" and "government decisions are not a done deal." The government sets and in- fluences both Medicare and private payer physician reimbursement rates; it dictates medical practice via PQRS, EHR, and other quality initiatives including the new Quality Payment Program; it enacts and enforces laws that can fine and/ or put ophthalmologists in jail; it controls the process for approving and paying for new technology; it funds research and sponsors pub- lic health initiatives; and it funds medical education. However, we can influence this through advocacy, Ms. McCann said. So what is advocacy? It's influencing public policy through lobbyists; comments, testimony, and white papers; political contributions; and coalitions. And most impor- tantly, it's you, Ms. McCann said. "You are your own best advocate." Politicians do care and want to hear directly from the people they represent. Physicians know firsthand how public policy is affecting their patients and practice, she added, and it's important to use technical knowledge to ensure the laws and regulations truly reflect practices. Editors' note: Ms. McCann has no financial interests related to her comments. Getting to know MIGS Several different types of microinva- sive glaucoma surgeries (MIGS) were discussed during a session. To start, many of these proce- dures are based on good fundamen- tal knowledge of angle anatomy and use of the gonioprism. Steven Sarkisian, MD, Oklahoma City, continued on page 164

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