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enzyme residues, even with prompt rinsing. 2 The task force has met with CMS, the Association for the Ad- vancement of Medical Instrumen- tation (AAMI), and the Food and Drug Administration (FDA) on the issue of routine enzymatic clean- ing of intraocular instruments. We think that many manufacturers are considering a worst case situation of heavily soiled instruments (e.g., with dried tissue or blood) when specifying enzymatic cleaning with- in their IFU. However, for minimally soiled cataract instruments that are promptly cleaned and rinsed, requir- ing routine enzymatic detergent use, based on worst case scenarios, unnecessarily exposes patients to the risk of TASS without a proven benefit. The task force is asking manufacturers to validate cleaning of intraocular instruments without requiring routine use of enzymatic detergent. ASCs are instructed to review and follow a set of national guide- lines for instrument processing. However, some guidelines that apply to all forms of surgery may be overly broad and may not be as relevant or applicable to intraocular surgery. This new OICS guideline document is intended to educate our respective society members and to provide ophthalmology-specific, evidence-based recommendations that may allow our members to adopt or defend certain longstand- ing practices that have come under increased regulatory scrutiny. The OICS Task Force guidelines are available on the ASCRS website, ascrs.org. EW References 1. Chang DF, et al. Evaluation of ophthalmic surgical instrument sterility using short-cycle sterilization for sequential same-day use. Ophthalmology. 2018. Article in press. 2. Tsaousis KT, et al. Comparison of different types of phacoemulsification tips. II. Morpho- logic alterations induced by multiple steam sterilization cycles with and without use of enzyme detergents. J Cataract Refract Surg. 2016;42:1353–1360. Contact information Chang: dceye@earthlink.net and Jeffrey Whitman, MD, and Mi- chael Romansky, JD, from OOSS. One of the task force's first ini- tiatives was a survey of OOSS-mem- ber ASCs. This showed that approx- imately half of the 182 responding ASCs used short cycle sterilization between sequential cases. In ad- dition, there was no difference in self-reported infection rates between those facilities using short and long sterilization cycles for sequential cases performed on the same day. A series of discussions and meetings took place between CMS and the OICS Task Force. As a result, allowances were made for contin- uation of short cycle sterilization for sequential same-day ophthal- mic cases with certain constraints. However, there was ambiguity with respect to published CMS guidelines, particularly over whether a full dry cycle (which in some popular ster- ilizers takes 1 hour) had to be used. For this reason, OICS Task Force members designed a series of studies of short cycle sterilization using the two most commonly used FDA- cleared sterilizers identified from the ASC survey. 1 Funded by ASCRS, OOSS, and AAO, this study estab- lished the safety and acceptability of short cycle ophthalmic instrument processing for sequential same-day surgery, even when the drying phase is interrupted if allowed by the ster- ilizer instructions for use (IFU). Another processing issue has been requiring routine use of enzymatic cleaning of ophthal- mic instruments prior to steriliza- tion, if specified by their IFU. The OOSS-member ASC survey showed that approximately half of respond- ing facilities do not use enzyme to clean intraocular instruments between consecutive cases. Again, there was no difference in self-re- ported infection rates between those facilities that did or did not em- ploy enzymatic cleaning routinely. Previous studies have shown that enzymatic residues on intraocular instruments are a leading cause of toxic anterior segment syndrome (TASS), and the task force referenced new studies from the Moran Eye Center, Salt Lake City, that show the difficulty of eliminating microscopic UPDATE In the journal Multifocal IOL after hyperopic refractive surgery Violette Vrijman, MD, Jan Willem van der Linden, PhD, Ivanka van der Meulen, MD, Maarten Mourits, MD, Ruth Lapid-Gortzak, MD How do those with previous hyperopic corneal refractive laser surgery fare with multifocal IOL implantation? In this retrospective case series, investigators considered this question. Included here were 40 eyes of 40 patients. At 3 months post-implantation investigators determined that patients had a mean spherical equivalent of 0.04 D and a mean correct- ed distance visual acuity of 0.01 logMAR. They found that 87.5% of eyes were within 1.0 D of emmetropia and 62.5% were within 0.50 D of em- metropia. Investigators concluded that there is generally good acuity in cases where a patient who has undergone surgery for hyperopia receives a multifocal IOL for either refractive lens exchange or cataract surgery. Refractive predictability with the multifocal lens was not influenced by the extent of the previous hyperopia. Cataract surgery following DALK and PKP Seika Den, MD, Shigeto Shimmura, MD, Jun Shimazaki, MD In this retrospective case series, investigators considered how prior deep anterior lamellar keratoplasty (DALK) or penetrating keratoplasty (PKP) affected the safety and efficacy of cataract surgery. Included were 30 eyes that had undergone DALK or PKP for conditions such as corneal stromal scars, lattice dystrophy, keratoconus, or post-herpetic keratitis, prior to phacoemulsification with insertion of an intraocular lens. Investigators determined that cataract surgery was successful in all eyes. In the DALK group, graft clarity after cataract surgery was found to be 90%, and in the PKP group it was 80%. At the 12-month mark, the PKP group had a significantly greater decrease in endothelial cell density than the group that had undergone DALK. Investigators concluded that for eyes that had undergone previous DALK or PKP, cataract surgery could be success- fully performed. In cases of corneal pathology and cataract, where there was an absence of endothelial involvement, investigators recommend DALK be followed by phacoemulsification, which they think may be beneficial in terms of reducing endothelial damage. Long-term outcomes for pediatric patients undergoing transscleral fixation of the capsular bag with intraocular lens for ectopia lentis Tahir Kansu Bozkurt, MD, Qiongyan Tang, MD, Lev Grunstein, MD, Tara McCannel, MD, Bradley Straatsma, MD, Kevin Miller, MD The aim of investigators in this retrospective case series was to consider how pediatric patients with ectopia lentis fared long term with trans- scleral fixation of capsular tension rings. Included were 67 eyes of 37 patients in which a capsular tension ring had been attached to the bag using transscleral fixation. In 78.5% of cases, postoperatively investi- gators found that there was an improvement in corrected visual acuity. Immediately postoperatively, IOL repositioning was required in one eye and one developed a hyphema. In the long term, 52% of eyes developed posterior capsular opacification, and one eye developed uveitis-glauco- ma-hyphema syndrome. Spontaneous delayed IOL dislocation requir- ing IOL repositioning occurred in three eyes. In two of the cases, 8-0 polytetrafluoroethylene was used to suture these postoperatively, and in the remaining case 9-0 polypropylene was used. Investigators con- cluded that in cases of pediatric patients with ectopia lentis, improved vision and IOL stability was attained with transscleral fixation of the capsular bag. EW April 2018 Multi-society continued from page 13 14

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