Eyeworld

Reporting from the Asia-Pacific Academy of Ophthalmology (APAO) Congress March 1–5, 2017 Singapore EW MEETING REPORTER 174 Keratoplasty and anterior segment reconstruction highlighted in cornea symposium A cornea symposium entitled "Penetrating Keratoplasty, Lamellar Keratoplasty, and Anterior Segment Reconstruction" focused on topics related to cornea and external eye diseases and eye banking. Charles McGhee, MD, Auck- land, New Zealand, discussed anterior segment reconstruction and the compromised iris and lens, particularly the problem of encoun- tering zonular/capsular insufficiency during cataract surgery. You need to be prepared for zonular weakness, he said, which includes taking a careful history and doing a careful exam- ination. There are typically three situations when this problem can arise: when there are signs preopera- tively, intraoperatively, or when it is created intraoperatively. Dr. McGhee briefly highlighted the etiology of zonular weakness. Then he highlighted 12 signs of zonular weakness, with six occurring preoperatively and six occurring intraoperatively. The preoperative signs are phacodonesis, iridodonesis, shallow anterior chamber, asym- metry of anterior chamber depth, pseudoexfoliation, and lens displace- ment. The intraoperative signs are poor pupil dilation, loss of capsular tension, wrinkling of the capsule, difficulty perforating the capsule, said the majority of countries have adopted the European Society of Cataract and Refractive Surgeons' (ESCRS) guidelines for using intra- cameral antibiotics, seeing a value in the decreased rate of endophthal- mitis found in the landmark ESCRS study from 2006 and in studies that followed confirming this research. Where surgeons in European countries might differ, Dr. Grzy- bowski said, is if they decide to also use topical antibiotics pre- and/or postop. Dr. Grzybowski also noted that Europe does have an on-label preparation of cefuroxime available and approved for intraocular use. A study of intracameral moxi- floxacin use was described by Ravil- la Ravindran, MD, Madurai, India. A group of patients that didn't receive intracameral moxifloxacin but received topical prophylaxis saw a 0.08% incidence of endophthal- mitis. In contrast, the group that received intracameral vancomycin saw an incidence of 0.02%. Intraca- meral moxifloxacin is now routine at Aravind Eye Hospitals, Dr. Ravilla said, going on to describe other studies that have shown a drop in endophthalmitis rates with use of intracameral moxifloxacin. Intracameral moxifloxacin has now been used in nearly 500,000 cases at Aravind Eye Hospitals. Dr. Ravilla said it can be given safely to significantly reduce the risk of endophthalmitis. Lam said that this is not the case, especially for young patients, recom- mending in addition that these cases are treated sooner rather than later. Prevention of endophthalmitis around the world Cataract Subspecialty Day kicked off at the APAO Congress with a session on endophthalmitis preven- tion. Chairman Tat Keong Chan, MD, Singapore, led the session by first paying tribute to the late Peter Barry, MD, a man who he said was a key person in endophthalmitis prophylaxis in ophthalmology. Presenters from different parts of the world shared practice patterns for endophthalmitis prevention in their region. Taraprasad Das, MD, Hyderabad, India, said povidone–io- dine is commonly used as standard of care prophylaxis in India. Dr. Das described a study that compared patients who received intracameral cefuroxime to patients who didn't, which found that there was little increase in postop endophthalmitis in the group that did not receive the intracameral antibiotic. As such, Dr. Das said intracameral antibi- otics might not be a necessity for all patients, but he said it could be beneficial for high-risk patients or in settings where community surgeries are taking place. Yong Zhong, MD, PhD, Bei- jing, China, said povidone–iodine irrigation is highly recommended in China, along with topical antibi- otics pre- and postop. The Chinese Cataract Committee does not recom- mend subconjunctival nor systemic antibiotics, Dr. Zhong said. In Australia, Jonathon Ng, MD, Perth, Australia, said there has been an almost 15-fold increase in intracameral antibiotics between 2003 and 2012. In the last 10 years, there has also been a decreased rate of endophthalmitis in Western Aus- tralia, though Dr. Ng noted that he can't say this decrease is due to the increase in intracameral antibiotic use. Chloramphenicol was the most common antibiotic used preopera- tively, intracamerally, and postoper- atively, Dr. Ng said. In Europe, Andrzej Grzybows- ki, MD, PhD, Olsztyn, Poland, April 2017

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