Eyeworld

137 March 2017 EW MEETING REPORTER axial length in combination with these factors that still allow for a free-floating capsulotomy. Dr. Lane said he doesn't neces- sarily agree with Dr. Fram's perspec- tive that her last case would have been better handled with a manual technique, which he said still has the potential for driving out with an Argentinian flag sign. This is less likely to happen, he said, with a laser in a closed system and pressur- ized eye. Editors' note: Dr. Cionni and Dr. Fram have financial interests related to their comments. DMEK learning curve During a section dedicated to cornea topics, Dr. Fram discussed Descem- et's membrane endothelial kerato- plasty (DMEK) and how to get out of the learning curve. DMEK offers faster recovery, greater percentage of BCVA at 1 year, less rejection and chronic steroid use, and the poten- tial for application with premium IOLs, she said. Dr. Fram highlighted patient selection for DMEK, suggesting that there are certain patients to avoid in the learning curve with this proce- dure, like those with large iris de- fects, ACIOLs, PPV, tubes and trabs, vitreous prolapse, poor visualization, or unwillingness to return to the OR. "Eye banks are getting better and better at providing pre-stripped tissue," Dr. Fram said. One sugges- tion she had was that older tissue could be easier to work with. Tissue from those aged 60–65 or older is less likely to scroll tightly, she said. Dr. Fram also recommended starting with cell counts of over 3,000, and she suggested that sur- geons not do a combined surgery in their first few cases of DMEK. She added that being sure the graft is not upside down is very important, and an S stamp can be particularly helpful with this. EW Editors' note: Dr. Fram has financial interests related to her comments. ing refractive superiority? It's Dr. Cionni's belief in this case that effective lens positioning (ELP) is the weakest link. "ELP remains an estimate even with LACS and intraoperative aber- rometry," Dr. Cionni said, adding that he uses a slightly different A constant for manual cases vs. femto cases. Dr. Cionni cited a 100 patient, contralateral cataract study where 92% in the FLACS group were within 0.5 D of target compared to 71% in the manual group. Refractive stability in the FLACS group was achieved within 1 week in the laser group compared to 1 month in the manual group. Dr. Cionni advocat- ed for more contralateral studies to compare FLACS vs. manual because it eliminates interpatient variability. Established benefits of FLACS include precise capsulotomy, lower CDE, and reduced endothelial cell loss, to name a few. Dr. Cionni said he also sees a benefit to FLACS in complicated cataract cases. Dr. Fram presented specifically on FLACS in white intumescent cat- aract cases. Even when there is evi- dence of a free-floating laser-created capsulotomy—indicated by bubbles all the way around the capsuloto- my—she still doesn't pull it toward the center, but around as she would in manual case. Where surgeons can get into trouble with FLACS in these cases is when they get milk, resulting in an incomplete cut. Dr. Fram showed such a case where she had only cut a couple of clock hours using the laser. She said she felt she was too far out with the cut to adequately control the remaining manual capsulorhex- is. "Did femto help me in this case? I think the answer is no," Dr. Fram said, noting that she thinks in hind- sight the spiral out technique would have been better. Dr. Fram is researching OCT pa- rameters that could be used to help decide which intumescent cataracts could benefit from FLACS. Dr. Fram said a spheroid lens in combination with a shallow chamber seems to be a contraindication for femto. How- ever, she added in some patients it's Patients present after recent cataract surgery, usually bilateral (though it has been described in uni- lateral cases), with subacute onset (1 to 14 days postop). Their vision loss is painless and is associated with anterior uveitis, diffusive occlusive retinal vasculitis, intensive intra- retinal hemorrhages in ischemic regions, and a negative ocular and systemic workup. These cases are thought to be a rare, type III hypersensitivity. Vanco- mycin is associated with a skin type III hypersensitivity, leukocytoclastic vasculitis. However, skin testing for a vancomycin sensitivity does not accurately predict HORV risk, Dr. Teske said. Treatment involves ag- gressive inflammation control, PRP, and anti-VEGF therapy. Last year ASCRS and the Amer- ican Society of Retina Specialists is- sued an alert regarding this possible association and formed a registry. Since then, vancomycin-associat- ed HORV has been reported in 23 patients, 36 eyes. Intracameral or in- travitreal vancomycin or vancomy- cin in the irrigation bottle was used in these cases. Sixty-one percent of these eyes are 20/200 or worse, 22% have no light perception, and 17% are 20/40 or better. Editors' note: Dr. Teske has no relevant financial disclosures. Is FLACS worth it? According to Market Scope research, 49.5% of U.S. surgeons offer femto- second laser-assisted cataract surgery (FLACS) or are planning to within the next 12 months, and 8.8% of cataract surgeries were FLACS in 2016, up from 6.6% the previous year. FLACS is growing, Dr. Cionni said, published literature, however, does not necessarily demonstrate refractive superiority over manual techniques. Dr. Cionni said a few studies have demonstrated refrac- tive superiority—quicker recovery, stability of outcomes, fewer HOAs, and ability to hit the refractive tar- get—but they are sparse compared to those showing no superiority. Why aren't studies demonstrat- than staining, Schirmer's, and tear breakup time, but a pure tear sample needs to be obtained before other drops are applied. Dr. Lane also mentioned MMP- 9 inflammatory mediator testing, tear volume testing with OCT, tear production testing, looking for irreg- ularities on topography and wave- front aberrometry, and Sjögren's blood testing. Dr. Lane called dynamic meibo- mian gland imaging (LipiScan, Tear- Science) a "game changer." This tool gives the patient a pictorial view of their glands, showing them the problem and making them amena- ble to treatment, Dr. Lane said. Dr. Yeu discussed the interven- tions available to treat OSD. Topical options include corticosteroids— which Dr. Yeu said are great for short-course therapy—cyclosporine A (Restasis, Allergan), lifitegrast (Xi- idra, Shire), and autologous serum. Device-based treatments include punctal plugs, microblepharon exfo- liation, intense pulsed light therapy, thermal pulsation, and Meibomian Gland Intraductal Probes (Rhein Medical, Tampa, Florida), the latter of which is intended for patients with no meibum secretion upon expression. Editors' note: Dr. Lane has financial in- terests with TearLab, TearScience, and Shire. Dr. Yeu has financial interests with Allergan, Shire, TearLab, Tear- Science, and BioTissue (Doral, Florida). The latest on vancomycin and HORV risk Asking for a show of hands from the audience, Michael Teske, MD, Salt Lake City, found that while many Surgical Summit attendees use intra- cameral antibiotics, only a few still use intracameral vancomycin. This drop in intracameral vancomycin use may be due to a possible association with risk of hemorrhagic occlusive retinal vascu- litis (HORV). The first series on this association was published in 2011, involving 11 eyes and six patients from different centers. The only common denominator was intraca- meral vancomycin.

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