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EW MEETING REPORTER 136 February 2018 Reporting from Hawaiian Eye 2018, January 13–19, Maui, Hawaii resembling glaucoma. Here, your best bet is taking a history from the patient, she said. The last potential misdiagnosis Dr. Wiggs mentioned was inflam- matory and demyelinating optic neuritis, which she said can produce an enlarged cup-to-disc ratio that correlates with RNFL thinning. In order to avoid misdiagnosis in these instances, Dr. Wiggs said that a clinical history is important to know the rate of progression, history of trauma, and age of onset. Family history of optic nerve disease can suggest inherited etiologies. Addi- tionally, OCT can help differentiate glaucoma for some conditions. Dr. Wiggs suggested considering neuro- imaging in patients with unilateral disease or vertically aligned visual field defects and neuroretinal rim pallor. She added that genetic testing can identify patients with inherited causes. During a panel discussion, Dr. Wiggs spoke about the use of ocular genetics to determine if someone has glaucoma. One of the possible categories of disease that can look like glaucoma is inherited optic atrophies, and those can be tested for using genetic testing. This is rela- tively inexpensive and makes it clear if the patient has inherited optic atrophy rather than normal tension glaucoma. "If you don't have a clear diagnosis, it's a helpful test," she said. diseases that could be misdiagnosed as glaucoma. Because some of these other diseases have systemic con- sequences, misdiagnosis can have serious results, she said. Dr. Wiggs spoke about a number of misdiagnoses. She first mentioned dominant optic atrophy, which has a large cup- to-disc ratio, and vertical elongation can mimic normal tension glau- coma. There are typically bilateral cecocentral visual field defects, however, these may not be present in up to 40% of patients. OCT can be helpful in differentiating these patients because there's a dramatic loss of nerve fiber layer thickness. Dr. Wiggs highlighted Leber he- reditary optic neuropathy (LHON). Diffuse atrophy in late stage LHON can look like normal tension glauco- ma, she said. In compressive or infiltrative lesions of the optic nerve, Dr. Wiggs said that compressive optic neurop- athy may cause cupping resembling glaucoma, as well as glaucoma-like visual field defects. Ischemic optic neuropathy is another disease that could be mistaken for glaucoma, and Dr. Wiggs said this can lead to increased cupping and cup-to-disc ratio asym- metry. "A tip-off here is that these patients almost always have very small cups," she said. Post-traumatic optic neuropathy can result in asymmetric cupping When questioned about trau- matic mydriasis, panelists generally agreed that they would go ahead and treat rather than defer. Editors' note: Drs. Chang, Donald- son, and Al-Mohtaseb have financial interests with various ophthalmic companies. Preoperative decision making in cataract surgery Denise Visco, MD, York, Pennsyl- vania, discussed avoiding refractive misses by taking FLACS to the next level. She first highlighted Lean Six Sigma, which is a methodology that relies on a collaborative team effort to improve performance by system- atically removing waste and reduc- ing variation. It involves segmen- tation of the surgical process, value stream mapping, identifying areas of waste and variation, and systems of accountability and execution, Dr. Visco said. Preoperatively, Dr. Visco stressed the education model, testing, and planning. Intraoperatively, she men- tioned laser programming, treat- ments, and surgery. Postoperatively, she highlighted tracking, follow-up, and enhancement. With laser focus on the two basic principles of reducing variables and eliminating waste, Dr. Visco said refinement of incisional refractive surgery will result in outstanding clinical outcomes in practice. Editors' note: Dr. Visco has financial interests with LENSAR (Orlando, Flori- da) and Oculus (Wetzlar, Germany). Avoiding misdiagnosis in glaucoma During her presentation "When glaucoma is not glaucoma: Keeping out of trouble," Janey Wiggs, MD, PhD, Boston, focused on non-glau- comatous causes of optic nerve dis- ease, some of which can be confused with glaucoma. The appearance of the optic nerve, measures of retinal nerve fiber layer (RNFL) thickness, and visual field defects are all important factors when diagnosing glaucoma, Dr. Wiggs said. However, optic nerve degeneration can be caused by other View videos from Hawaiian Eye 2018: EWrePlay.org David Chang, MD, discusses technology changes for IOLs that are on the horizon. Sponsored by

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