There were so many fantastic talks at Hawaiian Eye this past January that it warranted a “Part II” of highlights. These talks covered the gamut of subspecialties — below is a discussion of some of the covered topics.
Oculoplastic Surgery
Saturday morning was the kick-off featuring the Oculoplastic Symposium, which covered both functional and aesthetic topics and included a live injection workshop where botulinum toxin, dermal filler and Kybella injections were demonstrated.
The functional session started with a talk by Dr. Jeremiah Tao who discussed basic anatomy, including the lacrimal system, orbit and eyelid. Dr. Roger Dailey spoke on diseases affecting the lacrimal system and management of tearing problems, such as nasolacrimal duct obstruction and canalicular stenosis. And Dr. George Bartley gave a talk on various causes and management options for ptosis, including levator advancement and conjunctival-mullerectomy surgeries.
Dr. Andrew Harrison discussed his method for “Bullet Proof Upper Blepharoplasty.” Key points were to know your patient’s expectations before operating and take caution when removing too much orbicularis oculi and fat so patients do not end up with volume loss or lagophthalmos. Some patients may need a ptosis repair or lacrimal gland repositioning at the same time as the blepharoplasty. He then went over complications of blepharoplasty, including wound issues such as dehiscence and cysts, and then went on to discuss the dangers of orbital hemorrhage.
Ocular Surface
Dr. Ken Beckman discussed the treatment of dry eye patients prior to cataract surgery. There are three main reasons why one should ensure a healthy ocular surface prior to cataract surgery:
- Prevention of perioperative infections
- More accurate IOL calculations and accurate corneal measurements prior to surgery
- Attempt to prevent post-operative visual aberrations secondary to a poor tear surface.
Prior to surgery, Dr. Beckman gives an extensive dry eye evaluation, including a lid margin and tear film exam. He gets multiple corneal readings including IOL Master, Manual K’s, and corneal topography measurements. If the numbers do not correspond, he treats the ocular surface and brings the patient back until the tear film is stable before proceeding with surgery. Dr. Beckman is also hesitant to use premium IOLs in patients with a poor ocular surface.
Neuro-ophthalmology
Dr. Andrew Lee spoke about the importance of the chief complaint and pupillary exam to diagnose life-threatening diseases. If a patient uses the buzz words “acute and painful” in their chief complaint (acute and painful anisocoria, acute and painful ptosis, acute and painful diplopia, acute and painful visual loss, etc.) be alerted to the fact that they may have a neuro-ophthalmic process that is related to a life-threatening disease and needs to be addressed quickly.
Dr. Lee discussed how the pupillary exam has been delegated to ophthalmic technicians, which for the most part is fine, but in difficult cases, should be referred to the doctor for evaluation. For instance, if an abnormal pupil is associated with a droopy lid, visual loss, diplopia or motility disturbance, the doctor should evaluate, because likely there is a neuro-ophthalmic disease until proven otherwise.
Glaucoma
Dr. David Huang discussed the findings of the Advanced Imaging for Glaucoma Study — a large multicenter observational study including 500 eyes in early stages of glaucoma or glaucoma suspects.
The duration of the study was 10 years; patients were followed every six months with visual fields and OCT. The study looked at whether baseline OCT can predict future development of visual field defects and significant progression of glaucoma. They found that in general most of the nerve fiber layer and macular ganglion cell complex parameters were predictive of future visual field changes.
The most accurate predictor was the ganglion cell complex focal loss volume (GCC FLV). This parameter predicted visual field progression or conversion in their study. Reasoning behind the accuracy of GCC FLV is that focal damage is more specific to glaucoma damage, whereas a general reduction in thickness (nerve fiber layer or ganglion cell complex) can be secondary to magnification effects such as myopia or congenital thinness. Age, visual field pattern standard deviation and central corneal thickness also help with prediction. These parameters should be used together in a composite index to help predict glaucomatous pathology.
Retina
Dr. Pravin Dugel discussed the interaction between anti-PDGF and anti-VEGF. Pretreatment of wet AMD patients with anti-PDGF before using a combination therapy of anti-PDGF and anti-VEGF helps block the upregulation of PDGF. PDGF will recruit pericytes, which will cover the neovascular complex providing a protective armor and resistance to anti-VEGF therapy.
The patients who were pretreated with anti-PDGF in this study improved a mean of 20 letters in 18 months compared to the two letter improvement in patients who received combination treatment alone (without pretreatment). This is promising data and suggests the usefulness of anti-PDGF as a pretreatment.
Cataract
Dr. Neda Shamie presented her top 10 pearls for transitioning from traditional cataract surgery using phacoemulsification to cataract surgery using femtosecond laser.
The basic premise of her talk was that if you choose to transition to femtosecond laser, there are certain technique modifications that will help make the learning curve much faster. For instance, it is helpful to recognize which patients are ideal candidates preoperatively. Small pupils that do not dilate well are much more difficult, as the laser capsulotomy is harder to perform. Also, photodissection during the capsulotomy causes a cleavage plane of the cortex, making cortical removal more challenging.
Dr. Shamie recommends considering a second paracentesis port so one can potentially convert to a bimanual I/A, cortical removal. Hydrodissection is a bit different from the traditional method because the cavitation bubbles can get trapped behind or within the lens, altering the red reflex and the visualization of the hydrodissection wave. Some tips to address this issue are toggling the lens to move the bubble forward or doing gentle fluid waves all around the lens, and also using the air bubble for pneumodissection. For nuclear removal, the cracks have been cut by the laser, leaving little room to maneuver, requiring further toggling of the nucleus to get the pieces out.
We look forward to Hawaiian Eye 2017, January 14-20, on the beautiful island of Kauai, where there are sure to be another group of incredible talks. Stay tuned!