Eyeworld

EW MEETING REPORTER 86 Reporting from the American Academy of Ophthalmology (AAO) meeting, October 15–18, Chicago strong enough one until there is a commercially available product—at least, that is what many audience members decided during a debate at "Areas of Controversy Regarding Cataract Surgical Preferred Prac- tices." After listening to Francis Mah, MD, La Jolla, California, and Terrence O'Brien, MD, Palm Beach, Florida, weigh in on the topic, the audience had a close vote of about 51.5% to 48.5%, in favor of the superiority of intracameral antibi- otics in fighting endophthalmitis. Dr. Mah reiterated the results of the well-known ESCRS 2008 prospective study that found strong results in fa- vor of this approach. He also point- ed out the common problems with topical drops, such as lack of compli- ance and cost. Dr. O'Brien, speak- ing against the use of intracameral prophylaxis, cited the current low rate of endophthalmitis at Miami's Bascom Palmer Eye Institute without the use of intracameral antibiotics and said that intracameral use in the U.S. could come with the risk of di- lution errors, toxic anterior segment syndrome, contamination, and anaphylaxis allergy. Both speakers pointed out that, unlike in Europe, there is currently no commercial available intracameral formulation approved for use in the U.S. Editors' note: Drs. Mah and O'Brien have financial interests with Alcon. for more than 50% of the profes- sion/industry. There is also a trend toward early cataract surgery and a large shift from cornea to lens-based refractive surgeries. However, the industry is behind in innovation, he said. The last successful key innova- tion, Dr. Steinert said, was acrylic foldable IOLs, about 20 years ago. The last innovation with the most potential, he added, were multifocal IOLs, and that occurred 8 years ago. Dr. Steinert highlighted three things in his lecture: the treatment of presbyopia in emmetropes with near vision inlays, treatment of cataracts using a two-piece accom- modation intracapsular lens, and treatment of postoperative IOL error. He spoke about the recent approval of the Raindrop corneal inlay (ReVision Optics, Lake Forest, California). He also highlighted the LensGen AIOL (LensGen, Irvine, California), and using refractive index shaping (particularly Perfect Lens). Editors' note: Dr. Steinert has financial interests with Abbott Medical Optics, Alcon, Allergan, LensGen, ReVision Optics, and Perfect Lens. Intracameral antibiotics during cataract surgery Although there is an interest in intracameral antibiotic prophylax- is during cataract surgery among U.S. physicians, the option is not a important to get a detailed history, he said. This includes asking if the patient has blurred vision in the morning and asking open-ended questions. Endothelial cell count, pachymetry, and a slit lamp exam are also important. The endothelial cell count should not be used to de- termine the need for an endothelial keratoplasty (EK), Dr. Holland said. It's important to look for subtle signs of cornea edema at the slit lamp exam, like posterior stromal folds, stromal haze, and epithelial edema. The third pearl was to individu- alize each patient's visual needs and prognosis. The general guideline for stromal edema and any level of cata- ract is to use phaco/EK, Dr. Holland said. For guttata without evidence of edema, do phaco only, he said, with EK for symptomatic guttata. There are some notable exceptions to these general guidelines, like in cases with minimal edema, dense cataracts, or maculopathy. His fourth pearl was to change your phaco technique in Fuchs' patients. For dense cataracts, Dr. Holland said, chop all pieces in the bag and then remove under con- trol. You can work with small lens segments. Then, reapply OVD and make a larger capsulorhexis to allow greater area for manipulation of a large dense lens, he said. Use all techniques to make the case easier, he said. Consider a block for unco- operative patients, he said, and iris expanders can be helpful, even for a moderately small pupil. Dr. Holland's last pearl was to establish a relationship with a cor- neal specialist. The cataract surgeon and corneal surgeon need to provide the same message to the patient. It's comforting for the patient to know that you have a plan, he said. Editors' note: Dr. Holland has no finan- cial interests related to his comments. Kelman Lecture This year the Kelman Lecture was given by Roger Steinert, MD, Irvine, California, on "Cataract/Refractive Surgery: The Next Big Thing?" Cataract surgery dominates oph- thalmology, he said, with 25 million global procedures. Cataract accounts November 2016 View videos from AAO 2016: EWrePlay.org Anat Galor, MD, describes her protocol for dry eye diagnosis and treatment. continued on page 88 Sponsored by

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