Eyeworld

EW RETINA 122 March 2017 by Steve Charles, MD Management of vitreous floaters and asteroid hyalosis Dr. Charles discusses floaters and patient satisfaction T he most challenging aspect of managing patients who complain of floaters is de- termining if there are also psychological issues at play. It is common to see patients with very dense floaters and no visual complaints even when questioned intensely. On the other hand, we all see patients with minimal floaters on objective clinical examination who complain bitterly. Many of this latter cohort of patients also have anxiety disorders, depression, bipolar disorders, fibromyalgia, chronic fatigue syndrome, and/or chronic pain. Their list of medica- tions may be extensive. Surgery in such patients, especially if a retinal detachment is caused, may result in a very unhappy patient. Cataract progression after vitrectomy is nearly uniform if any pre-vitrectomy nuclear sclerosis is present. Age is a proxy for preoper- ative nuclear sclerosis. Vitrectomy increases the partial pressure of oxygen by 12 mm Hg permanently as shown by Nancy Holekamp, MD, Chesterfield, Missouri. This is because the viscosity is reduced about 1000-fold, enabling greater diffusion of oxygen. I do not recom- mend phacoemulsification–vitrecto- my because it produces suboptimal refractive outcomes if performed by vitreoretinal surgeons, and there is increased risk of retinal breaks and detachment if done by a cataract surgeon. Optical coherence tomography (OCT) recently has been found to be an excellent way of objectively evaluating floaters, more correctly termed vitreous condensations. The infrared image displayed with the OCT B-scan on the Heidelberg Spectralis (Heidelberg Engineering, Heidelberg, Germany) is also valu- able in evaluating floaters. Use of OCT is crucial because it also discov- ers ophthalmoscopically invisible macular pathology; often, the actual cause of visual loss is said to be due to floaters. Asteroid hyalosis virtual- ly never causes visual loss or requires vitrectomy. I do not recommend performing vitrectomy if a posterior vitreous detachment (PVD) is not present. When the PVD occurs later, the patient will need another vitrecto- my; creating a PVD at the time of surgery is likely to result in retinal breaks and detachment. If a decision is reached to do vitrectomy, careful peripheral retinal examination and laser prophylaxis of all retinal breaks at least 2 weeks before vitrectomy is essential. I evaluated YAG vitreolysis for coherence when the YAG was first introduced and recommended that the indication not be pursued. I subsequently evaluated picosecond laser vitreolysis and reached the same conclusion. I have evaluated many unsatisfied post-YAG vitreoly- sis patients on second opinion, some of whom had lens damage. I have heard many anecdotal reports of retinal damage as well. Many vitreo- retinal surgeons had evaluated YAG vitreolysis and were very negative at a town hall-style discussion at the 2016 Vit-Buckle Society meet- ing. In all instances, the lasers were purchased by their cataract surgery associate. EW Editors' note: Dr. Charles is chair of the ASCRS Retina Clinical Committee. He has financial interests with Alcon (Fort Worth, Texas). Contact information Charles: scharles@att.net Retina consultation corner View the EyeWorld CME and non-CME supplements at: cmesupplements. eyeworld.org supplements. eyeworld.org Supported by an unrestricted educational grant from Abbott Medical Optics Designation Statement The American Society of Cataract and Refractive Surgery designates this enduring materials educational activity for a maximum of 1.0 AMA PRA Category 1 Credits. ™ Physi- cians should claim only credit commensurate with the extent of their participation in the activity. Claiming Credit To claim credit, participants must visit bit.ly/2gVjCDk to review content and down- load the post-activity test and credit claim. All participants must pass the post-activity test with a score of 75% or higher to earn credit. Alternatively, the post-test form included in this supplement may be faxed to the number indicated for credit to be awarded, and a certificate will be mailed within 2 weeks. When viewing online or downloading the ma- terial, standard internet access is required. Adobe Acrobat Reader is needed to view the materials. CME credit is valid through June 30, 2017. CME credit will not be awarded after that date. Notice of Off-Label Use Presentations This activity may include presentations on drugs or devices or uses of drugs or devices that may not have been approved by the Food and Drug Administration (FDA) or have been approved by the FDA for specific uses only. ADA/Special Accommodations ASCRS and EyeWorld fully comply with the legal requirements of the Americans with Disabilities Act (ADA) and the rules and regulations thereof. Any participant in this educational program who requires special accommodations or services should contact Laura Johnson at ljohnson@ascrs.org or 703-591-2220. Financial Interest Disclosures John Berdahl, MD, has earned a royalty or derived other financial gain from Imprimis and Ocular Surgical Data. He has an investment interest in DigiSight, Omega Ophthalmics, and Vision 5. Dr. Berdahl has received a retainer, ad hoc fees or other con- sulting income from: Abbott Medical Optics, Alcon Laboratories, Avedro, Bausch + Lomb, Calhoun Vision, ClarVista, DigiSight, Enviseo, Glaukos, Imprimis, Ocular Therapeutix, Omega Ophthalmics, Ocular Surgical Data, Vision 5, and Vittamed. He is a member of the speakers bureaus of Glaukos and Ocular Therapeutix. Rosa Braga-Mele, MD, FRCSC, is a member of the speakers bureaus of Alcon Laborato- ries and Allergan. Daniel Chang, MD, has an investment inter- est in Omega Ophthalmics. He has received a retainer, ad hoc fees, or other consulting income from: Abbott Medical Optics, Allergan, Carl Zeiss Meditec, Mynosys Cellular Devices, and Omega Ophthalmics. Dr. Chang has received expense reimbursement from and is a member of the speakers bureaus of Abbott Medical Optics and Carl Zeiss Meditec. He has received research funding from Abbott Medical Optics and Mynosys Cellular Devices. Daniel Durrie, MD, has an investment inter- est in, has received expense reimbursement from, and has received a retainer, ad hoc fees or other consulting income from AcuFocus, Alphaeon, and Strathspey Crown. He has received research funding from AcuFocus, Alcon, Allergan, Avedro, and EyeGate Pharma. Dr. Durrie has received expense reimburse- ment from Avedro and Hoopes Durrie Rivera Research. Staff members: Kristen Covington and Laura Johnson have no ophthalmic-related financial interests. 365 Curriculum Presbyopia Presbyopia correction: Exploring surgical options, expectations, and postoperative error continued on page 2 by Daniel Durrie, MD Describing the stages of presbyopia: Understanding its onset and progression DLS stages Patients usually enter stage 1 of DLS at an average age of 43. In stage 1, the lens is clear and colorless, but the lens los- es the ability to change power. As a result, most patients have When we explain this to our patients, they understand it well. Previously, patients knew their eyes changed during middle age and that cataracts may develop later, but no one explained how the lens was changing. New terminology gains momentum in ophthalmic practices A new three-stage classification system is helping cataract surgeons communicate with their colleagues and patients about the normal phases of crystalline lens change that occur with aging. When we review the stages of dysfunc- tional lens syndrome (DLS), we not only describe the way the lens changes but can correlate these changes with treatments that are most ap- propriate at each stage. 1,2 Illustrative analogy During human embryon- ic development, a piece of ectodermal tissue splits off to become the crystalline lens. Consequently, it ages simi- larly to the skin. As disulfide bonds accumulate inside the lens through all three stages, the lens loses flexibility and density increases. " With new diagnostic tools, we can show patients the color, appearance, and density of the lens and how they affect vision. " –Daniel Durrie, MD Accreditation Statement This activity has been planned and imple- mented in accordance with the accreditation requirements and policies of the Accredi- tation Council for Continuing Medical Edu- cation through the joint providership of the American Society of Cataract and Refractive Surgery (ASCRS) and EyeWorld. ASCRS is ac- credited by the ACCME to provide continuing medical education for physicians. Educational Objectives Ophthalmologists who participate in this activity will: • Accurately describe the progressive diagnosis of presbyopia and the optical fundamentals of correction options, uti- lizing the appropriate current terminology of presbyopia to describe all stages of the disease state • Compare and contrast presbyopia treatment options to match solutions to patients' needs, and describe range of vision functions as related to patients' needs • Implement a lower threshold for accept- able pseudophakic refractive error levels in presbyopia-corrected patients, and identify steps to mitigate refractive sur- prises and other key variables to increase postoperative success EyeWorld January 2017 365 Curriculum OSD: Honing diagnostic protocols to pinpoint disease, enhance surgical outcomes Supported by unrestricted educational grants from Alcon Laboratories Inc., Allergan Inc., Shire Pharmaceuticals, TearLab, and TearScience continued on page 2 Accreditation Statement This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education through the joint providership of the American Society of Cataract and Refractive Surgery (ASCRS) and EyeWorld. ASCRS is accredited by the ACCME to provide continuing medical education for physicians. Educational Objectives Ophthalmologists who participate in this activity will: • Identify the true impact of a dysfunc- tional ocular surface on cataract and refractive outcomes, identify the conse- quences that accompany an unstable tear film, and discuss the presentation of symptomatic vs. asymptomatic OSD • Describe the objective evidence supporting the use of new OSD diagnostic tools and develop strategies for incorporating new diagnostic tools into practice, including: inclusion in point-of-care and preoperative testing, use of diagnostic information to guide treatment, and utilization of diagnostics to follow success of interventions or treatment • Improve practice protocols for the screening, diagnosis, and classifica- tion of OSD and integrate consistent treatment regimens Designation Statement The American Society of Cataract and Refractive Surgery designates this enduring materials educational activity for a maximum of 1.0 AMA PRA Category 1 Credits. ™ Physicians should claim only credit commensurate with the extent of their participation in the activity. Claiming Credit To claim credit, participants must visit bit.ly/2j9eZpt to review content and download the post-activity test and credit claim. All participants must pass the post-activity test with a score of 75% or higher to earn credit. Alternatively, the post-test form included in this supplement may be faxed to the number indicated for credit to be awarded, and a certificate will be mailed within 2 weeks. When viewing online or downloading the material, standard internet access is required. Adobe Acrobat Reader is needed to view the materials. CME credit is valid through August 31, 2017. CME credit will not be awarded after that date. Notice of Off-Label Use Presentations This activity may include presentations on drugs or devices or uses of drugs or devices that may not have been approved by the Food and Drug Administration (FDA) or have been approved by the FDA for specific uses only. ADA/Special Accommodations ASCRS and EyeWorld fully comply with the legal requirements of the Americans with Disabilities Act (ADA) and the rules and regulations thereof. Any participant in this educational program who requires special accommodations or services should contact Laura Johnson at ljohnson@ascrs. org or 703-591-2220. Financial Interest Disclosures Jessica Ciralsky, MD, has received a retainer, ad hoc fees or other consulting income from Abbott Medical Optics, Allergan, Bausch + Lomb, and Shire. Preeya Gupta, MD, has received a retainer, ad hoc fees or other consulting income from: Abbott Medical Optics, Alcon Laboratories, Allergan, Bio-Tissue, NovaBay Pharmaceuticals, RPS, Shire, TearLab, and TearScience. Francis Mah, MD, has received a retainer, ad hoc fees, or other consulting income from Abbott Medical Optics, Aerie Phar- maceuticals, Alcon Laboratories, Allergan, Bausch + Lomb, CoDa, NovaBay, Ocular Science, Okogen, Omeros, PolyActiva, Shire, Sun Pharma, Sydnexis, and TearLab. He is a member of the speakers bureaus of Alcon, Allergan, Abbott Medical Optics, and Bausch + Lomb. Dr. Mah has received research funding from Abbott Medical Optics and Allergan. William Trattler, MD, has an investment interest in Alphaeon, ArcScan, and CXLO. He has received a retainer, ad hoc fees, or other consulting income from, and is a member of the speakers bureau of: Abbott Medical Optics, Allergan, Avedro, Bausch + Lomb, Shire, and Sun Pharma. He has received a retainer, ad hoc fees or other consulting income from Alcon Laborato- ries, and is a member of the speakers bu- reau of NovaBay. Dr. Trattler has received research funding from Allergan. Staff members: Kristen Covington and Laura Johnson have no ophthalmic-related financial interests. I n our quest to im- prove cataract surgery outcomes, we use the latest formulas, IOLs, and surgical technologies. To make the most of the newest innovations, we need accurate preoperative measurements, but dry eye can interfere with these readings. To help patients achieve the best refractive outcomes, surgeons need to enhance their dry eye assessment protocols to more accurate- ly diagnose dry eye before surgery. Dry eye impact Many patients who are eval- uated for cataract surgery do Undiagnosed dry eye can have far-reaching consequences in cataract patients by William Trattler, MD The ocular surface: A key factor in patient dissatisfaction William Trattler, MD " To make the most of the newest innovations, we need accurate preoperative measurements, but dry eye can interfere with these readings. " –William Trattler, MD not have significant symp- toms of dry eye. However, during an objective examina- tion, which includes corneal staining, tear break-up time, and other tests, patients may have findings of ocular surface disease (OSD), which can impact preoperative imaging and IOL power calculations. EyeWorld February 2017 Ocular surface disease (OSD) The news magazine of the American Society of Cataract & Refractive Surgery digital.eyeworld.org Supplement to EyeWorld Daily News, Sunday, May 8, 2016 The news magazine of the American Society of Cataract & Refractive Surgery digital.eyeworld.org Supplement to EyeWorld Daily News, Monday, May 9, 2016 Innovative IOL technologies for the cataract surgeon

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