Eyeworld

109 February 2017 EW MEETING REPORTER What's in the tool box to handle these cases? Dr. Kahook said topical drops or intracameral medications can be used in these cases. He also discussed a number of surgical tools including iris retractors, the Malyugin ring (MST, Redmond, Washington), Beehler dilator (Moria, Doylestown, Pennsylvania), pupil stretching, APX expander (APX, Haifa, Israel), and the Beaver I-Ring (Beaver-Visitec, Waltham, Massa- chusetts). When he questioned the audience on what tools they used, nearly everyone indicated that they use the Malyugin ring. Dr. Kahook also discussed floppy iris syndrome, noting that initial clues can be subtle. He suggested looking carefully for iris billowing with normal irrigation, the iris moving toward or into wounds, and pupil constriction. It's important to look at pupil anatomy and preoperative dilation, he said, and if you find that you are dealing with a smaller pupil, start thinking about a medical plan and device surgical plan before going in, he said. Editors' note: Dr. Kahook has no finan- cial interests related to his comments. Other glaucoma topics Kuldev Singh, MD, Palo Alto, California, shared some thoughts on glaucoma care in the U.S., and he also discussed some of the myths and misconceptions. Only about 25 to 50% of people who have glauco- ma in the country know they have the disease, he said. Those who are aware are often not under care, and those under care are often noncom- pliant. There is also great variability in the natural history of the disease, he said. Only a small percentage of people go blind from glaucoma. Additionally, lowering IOP reduces but does not eliminate the risk of getting worse. He stressed several points of catching glaucoma early, avoiding aggressive therapy of early disease, targeting safety rather than IOP low- ering, the importance of follow-up, mostly when the patient is sitting up. What about the rest of the time? Does body position matter? How do different activities factor in? There are different options for IOP measurement, Dr. Katz said, including office curve at different times, using sleep labs, home to- nometers, and telemetry. Physicians are going to have to rely on home tonometry or telemetry, he said. For home tonometers, Dr. Katz mentioned two: the Proview (Bausch + Lomb) and Icare (Icare USA, Raleigh, North Carolina). He also mentioned the Triggerfish (Sensimed, Lausanne, Switzerland), a now-approved device that collects large amounts of data. Home eye pressure monitoring can increase the amount of valuable information, Dr. Katz said, includ- ing giving access to the highest IOP levels and amount of fluctuation. It could also help with fewer office vis- its, quicker adjustments in therapy, and documentation of non-adher- ence with medical therapy. Addi- tionally, the patient would have an increased role and involvement in his or her care. Editors' note: Dr. Katz has financial interests with Bausch + Lomb. Small pupils in cataract surgery Malik Kahook, MD, Aurora, Colora- do, spoke about how to handle small pupils in cataract surgery. A small pupil can interfere with almost every step of cataract surgery. It can cause poor red reflex and iris prolapse, among other problems. "Anticipation is key," he said. Anything you can know before going to the operating room will reduce stress, like knowing if the patient has risk factors for poor dilation, how well the patient dilates in clinic, how well the other eye dilated, the lens status, which tools are available in each OR, and if you should schedule a procedure as the last case of the day. Risk factors for small pupils include diabetes, pseudoexfoliation, alpha blockers, systemic conditions, complex surgery, synechiae, and prior laser photocoagulation. devices should be placed in the setting of an anterior or posterior capsular tear," Dr. Kim said. Editors' note: Dr. Donaldson has financial interests with Abbott Medical Optics, Alcon, and Allergan. Dr. Kim has financial interests with Alcon. Home monitoring of IOP L. Jay Katz, MD, Philadelphia, pre- sented on the topic of home moni- toring of intraocular pressure (IOP). This is an enormous unmet need in our field of ophthalmology, he said. IOP is an important risk factor for the development of progression of glaucoma. More than 50 years ago, it was shown that patients untreated with primary open angle glaucoma (POAG) had large swings in IOP over the course of the day compared to normal eyes. "But many studies out there show that more than 50% of peak IOP measurements fall outside of normal office hours," he said. So when physicians are in the office checking, they're missing many of the elevated IOPs. Furthermore, sleep laboratory studies are finding that some drugs do not work as well in the evening/sleeping hours. IOP is important for diagnosis, following patients, managing them, and adjusting for therapy, he said. But when measuring IOP in the of- fice, it's only done for a split second, weak zonules, he said. When eval- uating these patients, you should think about the etiology and make an assessment on the severity. The goal of a capsular tension ring is to apply outward force at the capsule equator and distribute forces to the entire zonular circumference, he said. It also postoperatively sta- bilizes IOL centration by reducing centripetal capsule and capsulor- hexis contraction. A CTR does not support the bag in the anteroposte- rior direction and can interfere with cortex aspiration, Dr. Kim added. This is in contrast to the capsu- lar retractor, which provides focal support of the peripheral capsular bag equator, as well as the capsu- lorhexis edge in the anteroposterior direction. Capsular retractors act as artificial zonules to achieve suffi- cient stabilization during phaco and minimize interference with cortex aspiration. A capsular retractor does not provide support postoperatively, Dr. Kim said. When choosing to use a CTR or capsular retractor, it's important to consider the timing of implan- tation, although he added you can really place these at any time. Dr. Kim prefers later implantation of a CTR and earlier implantation of a capsular retractor. You can place both immediately after CCC, during phaco/cortical aspiration, and prior to IOL implantation. "None of these continued on page 110 View videos from Hawaiian Eye 2017: EWrePlay.org Jay Pepose, MD, PhD, discusses methods for corneal imaging in preparing for multifocal IOLs.

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