This article is a follow up on last month’s piece, as there were too many great talks at Hawaiian Eye to fit into one article! Again, this covers talks across multi-specialties.
Cataract
Dr. John Hovanesian gave his pearls for achieving high patient satisfaction after cataract surgery. In his practice, he uses MDbackline — an automated follow-up care system that contacts patients one to two months post-surgery. Patients who have small refractive errors tend to expect more out of their results. Patients with 0.5 diopters or less of astigmatism after surgery are much more satisfied, as are those who are spectacle independent. He conducted a study looking at patients five years post cataract surgery and compared those who got accommodating lenses versus those who got multifocal lenses. Both groups did equally well as far as patient reported satisfaction, however, it is important to hit the refractive target and take into consideration co-morbidities such as dry eyes.
Dr. Eric Donnenfeld spoke on multifocal intraocular lenses and how they are the best for providing the full spectrum of correction for distance and near vision. A lot has been learned about these lenses over the year. Using a low add reduces glare and halos (i.e.: ReSTOR low add 2.5D, Tecnis 2.75D and 3.25D). There is also the Symfony® lens, an extended depth of focus lens that is a defractive lens at both distance and near, thereby reducing chromatic aberration. Using a negative spherical aberration lens and a lens with reduced chromatic aberration, make sure the ocular surface and retina are healthy. These new lenses provide full service quality vision to your patients.
Oculoplastic Surgery
Dr. Andrew Harrison spoke about small incision brow lifting. It is important to keep in mind when evaluating patients with “droopy” upper lids that sometimes ptosis of the brows can cause this issue, in which case a brow lift would be more ideal than a blepharoplasty. Brows can be lifted through an upper eyelid blepharoplasty incision using a suture-pexy. A newer method that was described by Dr. Guy Massry is an external brow-pexy. A small 1 cm incision is made above the superior brow hairs and, using a 4-0 prolene suture, the orbicularis oculi and retro-orbicularis oculi fat can be secured to the periosteum. Choosing between these two procedures can be decided by the thickness of the skin. If the skin is thin, puckering can occur with the internal incision, so one may choose the external approach. If patients have marked asymmetry, the external approach can be more precise in providing symmetry. Otherwise, both procedures can be effective.
Cornea
Dr. Thomas John spoke about tips and tricks for advanced techniques in corneal transplantation. If you have a monocular patient with corneal clouding where you can not see the anterior chamber very clearly, you may prefer to do an endothelial keratoplasty or an open sky technique, but there is risk of intraocular content prolapse which would be devastating. In such a case, if you use an intraoperative slit lamp you can visualize the anterior chamber through a very cloudy cornea to get the orientation of Descemet’s membrane and put a cannula in the appropriate position to inject air and detach Descemet’s membrane completely. Dr. John also uses (VisionBlue®) trypan blue to stain Descemet’s membrane. He presented a case showing that VisionBlue, with time, decreases the elasticity of Descemet’s membrane, which allows it to unfold easier. He recommends inducing a small pupil before introducing Descemet’s membrane, to prevent it from falling posterior.
Retina
Dr. Timothy Olsen discussed the economic benefit of placing a nationalized system for screening and treatment of retinopathy of prematurity. There have been three epidemics of retinopathy of prematurity — one in the 1940’s when ROP was found to be responsible for blindness in neonates. The second was in the 1970s when younger children, down to 24 weeks and with very low birth weight, were being rescued. The third epidemic has been occurring in middle income countries, such as Latin America and southeast Asia. Dr. Olsen and his group have taken this economic model into these countries and conducted analyses using family surveys from schools for the blind in Mexico, Peru, US and Philippines. They found that with a high level of economic and statistical analyses that there is a huge economic benefit from implementing a nationalized system for screening and treating ROP. For instance, in Mexico and the US, if a nationalized system were in place, each country would save over $200 million. Most of this cost is derived from having blind adults from ROP raising young children versus sighted adults who contribute to the gross domestic product.
Dr. Michael Ip updated attendees on the US-based SCORE2 trial and the UK-based LEAVO trial regarding available treatments for central retinal vein occlusion. There are multiple FDA-approved and off label treatments for the treatment of CRVO, including corticosteroid-based and anti-VEGF therapies. The NIH SCORE2 trial is a multicenter, prospective, randomized, phase III clinical trial that will compare the efficacy and safety of intravitreal aflibercept versus intravitreal bevacizumab. They will look at a six-month primary outcome time point where they will do a non-inferiority comparison with a 5-letter margin comparing these two therapies. The results will be presented at ARVO 2017. The UK-based LEAVO trial is also a multicenter, double-masked, randomized, controlled, phase III study comparing Lucentis, Avastin and Eylea for the treatment of macular edema secondary to CRVO. That study just completed recruitment 1 month ago and results will be coming in about a year and a half.
Glaucoma
Dr. Savak Teymoorian spoke about the advantages of using OMIDRIA® from Omeros in cataract surgery for glaucoma patients. There has been a strong push to use cataract surgery as first line surgery in glaucoma patients because you get a decrease in intraocular pressure by removing the cataract and one can combine micro-invasive glaucoma procedures at the same time. A wide pupil during cataract surgery in glaucoma patients is essential for better outcomes. Using OMIDRIA, which is a mixture of phenylephrine and ketorolac, will help prevent both miosis and inflammation and thereby reduce procedure time. Reduced procedure time will lead to better outcomes, especially when the procedure is combined with a glaucoma procedure, where clarity of the cornea is essential for visualization of the angle. Also, patients who are status post trabeculectomy or tube shunt surgery who develop cataracts have a risk of scarring of the prior bleb. The anti-inflammatory effects of OMIDRIA may help in this situation.
For those who were not able to attend the meeting this year, hopefully you can gain some insight through these articles. I encourage readers to consider joining us in 2018, as this is one of the most amazing ophthalmology meetings full of fantastic educational talks across multiple specialties.