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EW MEETING REPORTER 146 March 2018 Reporting from the 2018 Surgical Summit, February 1–3, Park City, Utah pressure spikes. He suspects that the procedure is creating micro-cyclo- dialysis clefts on either side of the implant. Dr. Vold said he gets these patients off steroids quickly, suspect- ing a steroid-related IOP spike. Dr. Rhee said there is a learning curve to implanting the CyPass. "I'm careful in making sure [when implanting the stent] that I don't drag in a lot of iris and rip open a lot of cleft," he said. "If I see iris tissue start to drag into it, I back off, go a little higher toward scleral spur, and it forms a higher cleft." Editors' note: The speakers have finan- cial interests with various ophthalmic companies. Patient expectations in refractive cataract surgery and retina topics During a session that highlighted both meeting the expectations of refractive cataract surgery patients and retina topics, Mitchell Weikert, MD, Houston, presented on astigma- tism correction and toric IOLs, high- lighting several important questions to consider. First, he discussed the best way to measure the cornea, mentioning manual keratometry, automated keratometry, and corneal topogra- phy/tomography. These methods provide different information, with manual/auto Ks providing numerical (quantitative) data and topography/ tomography providing both quanti- tative and qualitative data. What about the posterior cor- nea? Dr. Weikert said most measure- ments ignore the back of the cornea, so it's important to get accurate measurements. Surgeons may need to account for additional astigma- tism. Population averages for poste- rior corneal astigmatism are around 0.5 D in anterior with-the-rule astig- matism and around 0.3 D in anterior against-the-rule astigmatism. He also discussed if preoperative manifest refraction matters. Origi- nally, Dr. Weikert said, preoperative refraction was discounted and the cataract was removed, only corneal astigmatism mattered, and the measurements were based on the is a high IOP and low intracranial pressure causing a pressure differen- tial that induces glaucoma. "If we're right about this," Dr. Berdahl said of the theory regarding the pressure differential and the ability to equal- ize this with Balance Goggles, "then we have a non-surgical, non-inva- sive, non-pharmaceutical way to lower eye pressure and dial it in to where you want it to be." Dr. Berdahl said this idea also applies to long-term space flight where the goggles could be used to raise the eye pressure in astronauts to balance out their cerebrospinal fluid pressure and prevent optic nerve swelling and "hopefully help astronauts step on Mars one day." Dr. Vold also spoke about cor- neal refractive surgery for glaucoma patients. Overall, the risks for doing laser refractive surgery on glaucoma patients are diminishing due to im- proving technology. The top 10 red flags for corneal refractive surgery on glaucoma patients (some of which are the same for non-glaucoma patients) include systemic disease, unstable refraction, thin corneas, abnormal topography, eye disease, dry eye, presbyopia, occupation, in- appropriate expectations, and other specific contraindications. Addition- al preoperative testing for glaucoma patients should include OCT and visual field because, as Dr. Vold said, those with advanced disease are not the best refractive candidates. Challenges with laser refractive surgery in glaucoma patients can include their topical medications affecting the ocular surface; accuracy of IOP because thinner corneas can give a false IOP reading; IOP spikes during flap creation; monitoring glaucoma pressure postop, though Dr. Vold said this is less of an issue with imaging improvements; and postoperative dry eye. During a roundtable discussion, CyPass complications were brought up by the audience. One attendee asked about pressure spikes seen postoperatively in patients who ulti- mately ended up benefiting from the device. Dr. Berdahl said that the ear- ly postoperative period can be rocky with the potential for hypotony and compliance issues; and its potential for cost savings to patients if they're able to get off medications. Concerns, Dr. Rhee continued, include a risk of an IOP pressure spike potentially requiring surgical intervention (ALT carries a greater risk of this compared to SLT), the potential for failure of subsequent trabeculectomy (the jury is still out on this front), the potential for increased risk of bleb encapsula- tion, and the theoretical concern that repeat treatments could induce glaucoma. "Both patients and physicians alike strongly desire effective, sustainable solutions for glauco- ma care," said Steven Vold, MD, Fayetteville, Arkansas. "A topical glaucoma medication-free treatment paradigm offers improved vision, safety, and ultimately better quality of life for our patients." With the advent of MIGS, the ability to achieve this goal of a medication-free glaucoma therapy is possible. Dr. Vold went on to briefly present the current FDA-approved MIGS options, including laser tra- beculoplasty, Trabectome (NeoMe- dix, Tustin, California), Kahook Dual Blade (New World Medical, Rancho Cucamonga, California), Visco360/ Trab360 (Sight Sciences, Menlo Park, California), iStent (Glaukos, San Clemente, California), and CyPass (Alcon). Options for more advanced glaucoma patients include trabe- culectomy and tube shunts, but Dr. Vold noted the EX-PRESS (Alcon) and XEN (Allergan, Dublin, Ire- land) as potential options as well. XEN, Dr. Vold said, "changed how I practice with my patients with more moderate to advanced glaucoma." John Berdahl, MD, Sioux Falls, South Dakota, addressed another drop-free option that is in the works. Balance Goggles (Equinox, Sioux Falls, South Dakota) create a vacuum when worn by patients while they sleep. This, he said, balances the pressure differential across the optic nerve head, which is where Dr. Ber- dahl thinks glaucoma occurs. Dr. Berdahl described glaucoma as a two-pressure disease where there Sponsored by

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