Eyeworld

83 July 2017 EW MEETING REPORTER pupil. "That's why I designed the Malyugin ring," Dr. Malyugin said. The original Malyugin ring (Mi- croSurgical Technology, Redmond, Washington) comes in 6.25- and 7-mm sizes, it is inserted through a 2.4- to 2.5-mm incision, and gives eight points of iris retention, which avoids overextending the pupil. "This device was quite successful," Dr. Malyugin said, noting that it has been used in 1 million cataract surgeries. "But innovation never stops." The Malyugin ring 2.0 can be inserted through a 2-mm inci- sion. Its 5-0 polypropylene material makes it more flexible, which causes less compression to the iris tissue. The two ring designs have identical profiles, but the scroll depth of the newer version is bigger and provides easier engagement and disengage- ment of the ring. While there is 30% less compression force with the new ring vs. the original, Dr. Malyugin said he will still use the original in cases of fibrotic pupils. With either device, Dr. Malyugin operates under topical or injected lidocaine to avoid unwanted insertion. He injects an OVD bolus under the iris at the four scrolls of the device before insertion to lift it above the anterior lens cap- sule. When removing the ring, he presses on the lateral scrolls before they merge together, which Dr. Malyugin said helps them slide easily into the injector. EW studies show it has a 50% greater stretch compared to the manual capsulotomy. CAPSULaser has been used to create the posterior capsu- lorhexis in the lab and will begin human trials soon. The CE mark trial for the device, which included 124 eyes, is complete, with results expected in September, Dr. Packard said. Other devices for capsulotomy creation include the Zepto (Myno- sys, Fremont, California), a nitinol ring and suction cup, placed on the capsule through a 2.5-mm incision, which uses multipulse energy to cause a phase transition in water molecules to create the cut, and ApertureRx (International Biomedi- cal Devices, North Charleston, South Carolina), similar in design to the Zepto but without the suction ring. ApertureRx has not been used clini- cally, Dr. Packard said, and Zepto has received the CE mark. Wrapping up the symposium, Boris Malyugin, MD, PhD, Moscow, Russia, presented on pupil expan- sion devices, specifically iris hooks and the Malyugin ring, which he said should be used at the "end of the decision tree" after other forms of pupil dilation have failed. While hooks are easy to implant and are useful in cases of small pupils or weak zonules, Dr. Malyugin said one has to be careful to not over- extend the eye. Hooks also create a square pupil with the tendency to overstretch or traumatize the retinopathy, DME, and pseudopha- kic CME, Dr. Wong said. With a mild cataract, the priority is for treatment of diabetic retinopathy/DME. With a moderate cataract, adequate laser and a course of anti-VEGF treatment should be done before cataract sur- gery. For a severe cataract, early reti- nal follow-up and treatment may be needed. Adjunctive therapy during cataract surgery is useful if DME is present, Dr. Wong said, but is not needed if DME is absent. He added to beware of subtle DME, macular ischemia, and macular atrophy. Symposium shows "the way forward" with new innovations A symposium with the theme of finding "the way forward" highlight- ed innovations and technologies that might change how ophthalmol- ogists practice. Lin Haotian, MD, PhD, Guangzhou, China, present- ing on behalf of Liu Yi-Zhi, MD, PhD, Guangzhou, China, discussed research that shows promise in lens regeneration with endogenous stem cells in pediatric cataract patients. Richard Packard, MD, London, U.K., discussed new methods for cre- ating a capsulotomy. The first time the lens capsule was opened was in 1747, and since then, Dr. Packard said, the technique has remained mainly manual until recently with the introduction of the femtosec- ond laser-created capsulorhexis and other newer technologies. While the femtosecond laser creates truly circular capsulotomies of a consistent size and position with little risk of tear-outs, Dr. Packard mentioned several caveats to the technology. The advantage of circularity, sizing, and strength, however, result in more accurate outcomes, Dr. Packard continued, leading to the creation of other devices to create the capsulotomy. CAPSULaser (Los Gatos, Califor- nia) works by staining the anterior capsule, creating a selective target for a continuous laser, which is applied while the patient wears a contact lens and creates laser energy that facilitates a molecular phase change. The resulting capsulotomy has a high degree of elasticity and strength. In fact, Dr. Packard said choice. But more recently, treatment options have shifted to include in- travitreal steroids and now intravit- real anti-VEGF treatment. Dr. Wong noted that if the DME is not centered, lasering at the area of the DME continues to be the standard of care. If you have center DME, he said, anti-VEGF treatment is the standard of care. Anti-VEGF therapy reduces DME and improves vision, he added. Many patients now have severe DME, and even bilateral disease, and may need intensive treatment over time. There are more than 50 ran- domized trials looking at anti-VEGF treatment for DME. Dr. Wong highlighted several key points relating to DME. First, physicians need to understand the natural history of DME. The decline in vision is not dramatic. Because of this, surgeons should take the time to talk to patients and their family. Switching patients from a routine yearly or half yearly follow-up to an intensive monthly treatment may be a good option, he said. The next point that Dr. Wong highlighted was that vision im- provement with treatment is slow. The concept of a "three-loading dose" does not apply for DME, he said. Instead, the chronicity of DME is reflected in the "five- to six-load- ing dose." The maintenance of DME is less intensive over time. Dr. Wong said this is good news for patients because the burden is less over time. You need to treat early, he said, but then you need less treatment over time. Next, he touched on the po- tential differences among the three agents used. In eyes with poorer visual acuity (VA) at baseline, af- libercept appears superior to ranibi- zumab and bevacizumab in year 1, Dr. Wong said. All anti-VEGF agents are efficacious, he said, but surgeons may want to consider aflibercept in eyes with poor VA. In conclusion, Dr. Wong said that cataracts are a common comor- bidity of patients with diabetes, and systemic control helps to prevent cataracts. Cataract surgery is associ- ated with increased risk of diabetic View videos from APACRS 2017 EWrePlay.org Sumit Garg, MD, discusses how to select the appropriate presbyopia procedure by assessing patient needs.

• Blank Page
• Blank Page (1)