The Hawaiian Eye 2012 program for comprehensive ophthalmologists recently concluded in Maui. There continues to be daily breakfast and lunch seminars, as well as three days of afternoon workshops. In addition to the standard papers, there are also two popular video complication panel discussions, one on cataract and one on refractive surgery. A new feature this year was the Banyan Tree sessions—small group discussions on select topics—that were held in the early evenings. The bulky program book has been replaced by a brief course outline. Now the handouts for the talks are accessible via the web. Here are some highlights from the meeting:
Cataract/IOL
Surgical strategies and techniques: there were a number of talks addressing methods for handling difficult cases, such as patients with IFIS, shallow anterior chamber, pseudoexfoliation, previous refractive surgery, and ocular surface problems. One of the key take home messages was the importance of careful preoperative screening, especially with corneal topography.
Premium IOLs: this was also a major subject of discussion, in particular, strategies for creating happy presbyopic IOL patients.
- Dr. John Wittpenn revealed data on the potential adverse effects of generic topical NSAIDs. These drugs have shown significant complications (i.e., discomfort, SPK, corneal melts, patient intolerance and noncompliance with resulting CME) compared to the brand name medications. This raises an interesting ethical issue: what is the physician’s duty to inform patients about these possible effects?
- Drs. David Hardten and Eric Donnenfeld cited the importance of addressing dry eye and blepharitis and optimizing the ocular surface in order to create happy patients.
- Dr. Roger Steinert showed an algorithm to simplify the postop management of these patients to create excellent outcomes.
- Dr. Richard Lindstrom presented his experience with the RevitalVision system for visual cortex training. Patients had an improvement in visual acuity (average of 1.2 lines of distance vision and 0.7 lines of near vision) after 2 months of the computer-based training. He suggested that this is an option for the dissatisfied multifocal IOL patient.
- Dr. Frank Bucci Jr. gave an update on his ongoing study of mixing and matching premium IOLs. He now prefers to implant the Tecnis multifocal lens in both eyes.
- Drs. John Vukich and John Hovanesian discussed current and future accommodating IOL designs. Although this is an exciting topic, they both voiced a concern all US surgeons have: unfortunately our patients will not have access to most of this technology for years after it is available in the rest of the world due to the slow FDA approval process.
- Dr. Randall Olson presented a novel technique (refractive index shaping) for correcting residual refractive errors in patients with an implanted IOL. This exciting approach utilizes a special laser to modify the refractive index of the central portion of an IOL postoperatively to correct up to 3 D of ametropia.
Femtosecond laser cataract surgery: a mini-symposium was devoted to this hottest topic in ophthalmology. It consisted of presentations from surgeons with experience performing procedures with the various FDA approved devices (Alcon’s LenSx laser, Optimedica’s Catalys System, and LensAR’s laser).
- Dr. Barry Seibel discussed the different types of patient interface and docking strategies (curved applanating compared to liquid noncontact). The advantage of the liquid noncontact interface is that it does not distort the cornea. An applanating lens can cause corneal folds that may interfere with imaging and laser cuts.
- Dr. Mark Packer reviewed the imaging and guidance systems (OCT vs. CSI, and automated vs. manual). The automated systems are able to rapidly and accurately identify the ocular tissue surfaces and create safety zones.
- Drs. Eric Donnenfeld and Vance Thompson summarized their experience with laser astigmatic incisions and laser cataract surgery, respectively. They both noted how easy it has been to incorporate this technology into their practices and how the patients have embraced it.
Finally, Mr. Alan Reider addressed the biggest concern regarding this technology: how to pay for the treatments. He outlined the present CMS guidelines and various interpretations for different patient scenarios.
Ocular Surface Management
This two-part session covered all aspects of ocular surface treatments. There were presentations on imaging technology, surgical techniques (amniotic membrane, tissue adhesive, DMEK, ALK, and collagen cross-linking), and disease (tumors, dry eye, blepharitis, allergy, and HSV infection). Technology updates included:
- Dr. Helen Wu reviewed the management of ocular surface tumors and noted that ultra high resolution OCT is helpful for following lesions before and after treatment.
- Dr. Henry Perry discussed devices for the diagnosis of dry eye, specifically the TearLab osmolarity test and the InflammaDry detector for MMP-9 levels. These new tests are quite sensitive in detecting dry eye.
- Dr. Marguerite McDonald talked about new ideas in blepharitis and the role of the LipiFlow device and IPL therapy. She outlined her step-wise approach to treating this common condition.
Refractive Surgery
The final day of the meeting was dedicated to presenting a wide range of papers: keratoconus screening algorithms, corneal collagen cross-linking, corneal inlays, PRK, LASIK, residual astigmatism, phakic IOLs, and new accommodating IOLs.
- Drs. Minoru Tomita and Jay Pepose reviewed data on the Kamra corneal inlay for presbyopia, which resulted in improvements in near and intermediate vision with no loss of uncorrected distance visual acuity and no change in contrast sensitivity or stereopsis. This approach holds promise for improving near vision in our presbyopic patients.
- Dr. Marguerite McDonald discussed the Nexis shield, a novel treatment that reduces pain and accelerates healing after PRK. Preliminary results indicate re-epithelialization in 60% of patients at 2 days and 100% at 3 days postoperatively. This appears to be a promising technology that PRK surgeons and patients will benefit from.
- Dr. Bradley Randleman presented the results of collagen cross-linking for keratoconus and ectasia after LASIK. The study demonstrated that this treatment is effective at stabilizing and partially reversing the ectatic process. This is the standard of care outside the US and hopefully will be FDA approved soon so that US surgeons can begin to treat patients with unstable corneas.
- Dr. David Hardten stressed the importance of identifying irregular astigmatism and not using toric IOLs in these patients. He mentioned a website (astigmatismfix.com) that is helpful for addressing postoperative residual astigmatism after toric IOL implantation.
- Dr. Alan Faulkner shared his success with monovision LASIK and screening patients using a +1.25 D swinging lens with trial frames. He noted that a significant proportion of patients actually prefer their dominant eye to be corrected for near, so this should be remembered when performing a monovision trial.
- Drs. Karl Stonecipher and Vance Thompson gave updates on phakic IOLs including the toric ICL, ICL V4c design with aquaflow, Veriflex, and Cachet lenses. Once again, these cutting edge technologies are available outside the US but not yet FDA approved.
- Dr. John Hovanesian reviewed new generation accommodating IOLs such as the toric Crystalens, Synchrony lens with aspheric optics, AkkoLens, Tetraflex, NuLens, and Fluid Vision IOLs. Some of these novel designs allow up to 10 D of accommodation.
The session concluded with Mr. Shareef Mahdavi sharing his pearls for marketing premium cataract surgery.