Eyeworld

145 March 2018 EW MEETING REPORTER and can be used under topical an- esthesia; multiple adjustments can be performed; premium functions such as multifocality or toricity can be added or removed; and no special protective spectacles are needed afterward, among other features. The femtosecond laser can be used to perform refractive index shaping on hydrophilic or hydro- phobic acrylic IOLs in vivo. So far, research has shown that optical quality is maintained after laser- induced refractive changes and biocompatibility was demonstrated in the rabbit model. Editors' note: The speakers have finan- cial interests with various ophthalmic companies. Glaucoma spotlighted in general session Douglas Rhee, MD, Cleveland, discussed laser trabeculoplasty, in particular its benefit as a first-line treatment. Dr. Rhee explained that laser trabeculoplasty enhances outflow with delivery of laser energy to the trabecular meshwork. Argon laser trabeculoplasty (ALT) pulls open adjacent trabecular meshwork (there is no flow where the burn actually occurs), while selective laser trabeculoplasty (SLT) causes cellular loss and a wound response that results in cell proliferation and repopulation. "It's like you're rejuvenating that area," Dr. Rhee explained of SLT, and as a result, it increases drainage through the trabecular meshwork. Advantages of laser trabec- uloplasty include effective IOP control compared to medications; less variation of diurnal IOP com- pared to medications; its successful application in younger patients; its potential to eliminate medication Kendall Donaldson, MD, Plan- tation, Florida, discussed what can go wrong with use of the femtosec- ond laser in cataract surgery. Lens tilt and an uncomfortable/moving patient can result in an incomplete capsulotomy; complex grid patterns can create poor visualization of the capsulotomy; and folds in the cornea are a warning sign for the possibility of capsulotomy tags. Dr. Donaldson also referenced issues with corneal incisions (diffi- culty opening, difficulty sealing, and difficulty of the laser detecting the limbus). As such, she said she has moved away from using the femto- second laser for the primary incision and paracentesis in favor of manual incisions. FLACS can also induce miosis, which is usually reversible, but some cases don't respond to pharmaceu- tical forms of pupillary expansion, Dr. Donaldson said. Cortex removal after FLACS can be more challeng- ing. Dr. Donaldson said her team performed comparative research that found cortical removal after FLACS took twice as long as manual cata- ract surgery. Even with these "femto bloop- ers," Dr. Donaldson said that femtosecond laser cataract surgery is extremely safe and effective, noting that the technology continues to improve and early issues are much less frequent now. Nick Mamalis, MD, Salt Lake City, highlighted the use of a fem- tosecond laser for in vivo postop IOL power adjustment, a technology and technique being pioneered by Perfect Lens (Irvine, California). "This is the most exciting tech- nology that I've seen recently," Dr. Mamalis said, adding that his team is in the process of submitting for approval for the first clinical trials to take place in humans soon. According to Dr. Mamalis' pre- sentation, the Perfect Lens femtosec- ond technology is noninvasive, fast, available; use frequent application of dispersive OVD; reduce fluidics if possible; chop rather than sculpt; and use phaco at the iris plane or capsule bag. Finally, in terms of corneal shape abnormalities, Dr. Masket highlighted keratoconus, which he said has challenges in lens options. Editors' note: Dr. Masket has financial interests with a number of ophthalmic companies. Cataract challenges continued Nicole Fram, MD, Los Angeles, covered the different forms of IOL fixation techniques—sutured to the iris, sclera, or capsule; capsule fixated with optic capture or reverse optic capture; and intrascleral glued or flanged techniques—and provid- ed pearls within several video case presentations. One of these was how to avoid an oval pupil in a case of iris suturing. Dr. Fram said to make sure you are mid-peripheral enough; don't tie the suture too tightly; and if the pupil is oval, use a Sinskey hook to untuck the tissue. Dr. Fram provided a large incision scleral fixation checklist. It included Gore-Tex CV8 threaded through a TTc-9 needle, a 23-gauge anterior chamber maintainer or posterior infusion, a 23-gauge MVR blade equivalent, and a 25-gauge GRIESHABER MAXGRIP forceps (Alcon, Fort Worth, Texas) or MST series (Redmond, Washington). Dr. Fram said one shouldn't use Gore- Tex with Hoffman pockets due to the possibility of knot protrusion. In general, if the capsular bag can be used, optic capture or reverse optic capture (best with intact zonules) is preferred. Iris suture fixation can be used provided there isn't significant iridodonesis or iris atrophy. When there is not capsule support, options include suture fixation to the sclera or intrascleral haptic fixation techniques. The goal in dealing with these patients is to try to allow the eye with an abnormal cornea to have a typical postoperative course and outcome, he said. It's also important to prevent worsening of the corneal disease when possible. It may be necessary to alter the technique or adopt new technology and methods. Dr. Masket first highlighted stromal disease, noting that visibil- ity is often a problem at surgery for these patients. He suggested remov- ing the epithelium, applying HPMC, and staining the capsule. He added that it's important to pretreat with oral antivirals and to stage surgery, if possible, for IOL power calculation post-PKP. Those with irregular astig- matism with scars are not candidates for keratoplasty. The post-refractive cornea may refer to an incisional or laser ablative procedure. For the incisional post- RK patient, Dr. Masket said there may be hyperopic progression and fluctuation. There may also be issues with IOL power calculations (poten- tial hyperopic surprises, difficulty obtaining the flattest K). Dr. Masket said to avoid the transsection of RK/ AK cuts, and to avoid multifocal and small diameter IOLs. He stressed the value of formu- las and technologies available to help with IOL power selection. Surface disorders could include a variety of conditions, like dry eye, epithelial basement membrane dystrophy, pterygium, and stem cell failure. Dr. Masket highlighted the importance of using topography. In endothelial disease, you don't want to worsen the cornea. Dr. Masket said there may be indica- tions for use of the femtosecond laser in some of these cases; he finds the laser most helpful with compromised endothelium, shallow AC, dense cataracts, zonulopathy, and with capsule issues. Particularly for the compromised endothelium, Dr. Masket said to use FLACS when Surgical Summit continued on page 146

• Blank Page
• Blank Page (1)