Ophthalmology Videos - OphthalmologyWeb

Topic 1: Unique Properties of Elevation Based Topography

Wed, 04 Aug 2010 00:00:00 GMT

Michael W. Belin, M.D., Professor of Ophthalmology University of Arizona Health Sciences discusses the unique properties of elevation based topography.

Topic 2: Screening for Keratoconus: Belin/Ambrosio Display

Wed, 04 Aug 2010 00:00:00 GMT

Michael W. Belin, M.D., Professor of Ophthalmology University of Arizona Health Sciences discusses screening for keratoconus.

Topic 3: Other Clinical Uses of the Pentacam: Cataract, Glaucoma, Cornea

Wed, 04 Aug 2010 00:00:00 GMT

Professor of Ophthalmology University of Arizona Health Sciences discusses other clinical uses of the Pentacam.

"Top 10 Reasons for Not Complying with Glaucoma Eye Drop Treatment"

Wed, 28 Jul 2010 00:00:00 GMT

Here's a video from Lumenis SLT that addresses reasons for patient non-compliance with a glaucoma eye drop regimen. A recent survey among glaucoma patients shows the following reasons, among others, for non-compliance: denial of the problem, cost of the eye drop treatment, difficulty of the regimen, unpleasant outcomes or side-effects of the treatment, lack of trust that the treatment will relieve symptoms, apathy, and previous experience (the condition returned after previous treatment). All reasons for patients to seriously consider SLT to treat glaucoma.

Blood Vessel Growth and Maturation

Fri, 28 May 2010 00:00:00 GMT

Dr. Patricia D'Amore from the Schepens Eye Research Institute discusses blood vessel growth and maturation.

Rob Brass, M.D. on How the RTVue OCT Measures Keratoconus and Images the Cornea

Wed, 26 May 2010 00:00:00 GMT

Rob Brass, M.D., Associate Clinical Professor at Albany Medical College, explains how the RTVue Optical Coherence Tomographer measures the cornea, aiding in the evaluation and diagnosis of keratoconus, DSAEK, Fuchs Dystrophy, corneal ulcer, thin cornea and other corneal irregularities.

David Huang, M.D. on Corneal Power Measurement and IOL Power Calculation with Optical Coherence Tomography

Wed, 26 May 2010 00:00:00 GMT

Dr. David Huang discusses OCT-based corneal power measurement and IOL calculation.

David Huang M.D. on Doppler Optical Coherence Tomography Measurement of Retinal Blood Flow

Wed, 26 May 2010 00:00:00 GMT

Dr. David Huang discusses the measurement of retinal blood flow using OCT.

Yaron S. Rabinowitz M.D. Discusses Collagen Cross Linking and OCT

Wed, 26 May 2010 00:00:00 GMT

Dr. Yaron S. Rabinowitz discusses how OCT is used to screen and monitor cross linking patients.

Alphasphere Orbital Sphere Implant: Surgical Pearls

Wed, 26 May 2010 00:00:00 GMT

AlphaSphere is a spherical orbital implant for use after enucleations that was recently developed and released by Addition Technology. This implant differs from others currently on the market because of its material makeup that lends to a host of other characteristics that make this implant unique.

ifa systems Presents Their Ophthalmology Software Solutions

Mon, 26 Apr 2010 00:00:00 GMT

The ifa group provides eye care software and services, e.g. EMR specialized in ophthalmology, management software for ophthalmologists and interfaces to billing systems and more than 400 ophthalmic devices. ifa systems, a member of IHE eye care, has been on the market for more than 20 years. The software features include drawing tools, statistical analysis, SNOMED compatible terminology databases etc. All software applications are available in 7 languages (English, German, Spanish, Italian, Portuguese, Dutch and Finnish). Services include IT-consulting, integration service, training and support (24/7 hotline).

ECR Vault: The Document and Image Scanning Solution for OfficeMate Users

Mon, 04 Jan 2010 00:00:00 GMT

ECR Vault is a new product that interfaces with Office Mate software which enables you to scan and remove all of the paper patient records from your office. If you are looking to start using EMR, ECR Vault is the paper-to-digital bridge that will allow you to go paperless.

An Interview with Prof. Donald Tan on the New Tan EndoGlide for DSAEK Surgery

Mon, 14 Dec 2009 11:23:00 GMT

Dr. David Goldman interviews Prof. Donald T. H. Tan, Director of the Singapore National Eye Centre. Prof. Tan offers his insight on the design and use of the Tan EndoGlide, a new medical device designed for DSEK / DSAEK surgery which allows surgeons to insert endothelial tissue while minimizing iatrogenic damage. Prof. Tan offers surgical pearls and discusses the benefits of the device.

David Goldman, M.D. Interviews Wendy Lee, M.D., M.S. about ASOPRS Meeting Highlights

Thu, 03 Dec 2009 00:00:00 GMT

Dr. David Goldman interviews Dr. Wendy Lee of Bascom Palmer Eye Institute. Dr. Lee discusses some of the highlights from the recent ASOPRS meeting. Dr. Lee discusses differences between the two dermal fillers currently on the market (Botox and Dysport); considerations for each are highlighted. Dr. Lee talks about the new dermal fillers that are coming to market. Other highlights from ASOPRS were face transplants, small incision and endoscopic surgical techniques, and MRSA.

Wendy Lee M.D., M.S. Interviews David Goldman M.D. about New Medications and Technologies for Cataract Surgery

Thu, 03 Dec 2009 00:00:00 GMT

Dr. Wendy Lee interviews Dr. David Goldman of Bascom Palmer Eye Institute. Dr. Goldman talks about a new, stronger, steroid medication that he is using for patients in his ophthalmic practice, and how he is monitoring the outcomes of its use. Dr. Goldman also touches on femtosecond laser surgery for cataracts. He looks forward to the future of IOLs, when the smaller incisions from femtosecond cataract surgery will allow for the possibility of gel intraocular lenses.

The FCI Snug Plug: One-Size-Fits-All Silicone Punctum Plug

Wed, 02 Dec 2009 00:00:00 GMT

The FCI Snug Plug punctual plug is a long lasting, simple and effective solution for dry eye syndrome.

Wendy Lee, M.D., M.S. Interviews Carmen A. Puliafito, M.D., M.B.A. about AAO 2009 Highlights

Tue, 01 Dec 2009 00:00:00 GMT

Dr. Wendy Lee interviews Dr. Carmen Puliafito, Dean of the Keck School of Medicine of USC. Dr. Puliafito touches on retina and cataract highlights from AAO 2009 including a novel retinal vein occlusion treatment, and results from the SCORE study. Dr. Puliafito also notes the "dramatic" results from the phase III clinical trial for Lucentis. Notable advances in technology for 2009 include high-resolution spectral domain OCT and the promising emergence of femtosecond high repetition rate lasers for laser-based cataract surgery.

David Goldman, M.D., Interviews Lauren Shatz, M.D., on Pearls for Implementing EMR

Wed, 25 Nov 2009 00:00:00 GMT

Dr. Lauren Shatz offers some pearls for transitioning to EMR in ophthalmic practice. Dr. Shatz discusses choosing EMR, nuances of EMR modules, as well as the initial time investment that it takes to implement EMR. Dr. Shatz also touches on the efficiencies that are the payoff for transitioning to EMR.

Wendy Lee, M.D., M.S. Interviews Kyle Alliman M.D. about AAO 2009 Highlights

Wed, 25 Nov 2009 00:00:00 GMT

Dr. Wendy Lee interviews Dr. Kyle Alliman about the highlights from AAO in San Francisco. Dr. Alliman reviews the injectable medicine studies that were presented at AAO. Dr. Alliman also touches on exciting technologies from AAO including Spectral Domain OCT and handheld OCT for intraoperative OCT.

Luis Cadarso on Anterior Segment OCT for the Refractive Surgeon

Thu, 05 Nov 2009 00:00:00 GMT

Luis Cadarson of Vigo, Spain discusses anterior segment imaging using the OCT for corneal pathology, refractive surgery, and keratoconus.

Jay Wei Founder & President/CEO, Optovue Inc., on Defining the OCT Revolution

Thu, 05 Nov 2009 00:00:00 GMT

Jay Wei of Optovue Inc. introduces the new Optovue iVue - The World OCT

Bruno Lambroso of Italy on New Possibilities for Optovue OCT: Choroid Exploration

Thu, 05 Nov 2009 00:00:00 GMT

Bruno Lambroso of Italy discusses choroid exploration using the Optovue RTVue OCT, including physiology, pathology and anatomy.

Prof. Dr. Keiki R. Mehta on the RTVue for Diagnosis and Management of Glaucoma

Thu, 05 Nov 2009 00:00:00 GMT

Prof. Dr. Keiki R. Mehta discusses use of the Optovue RTVue for diagnosis and management of glaucoma, including an overview of the RTVue normative database.

Vikas Chopra, M.D. on Macular Imaging for Glaucoma Using Optovue RTVue

Fri, 23 Oct 2009 00:00:00 GMT

Vikas Chopra, M.D. discusses macular imaging for glaucoma using the Optovue RTVue. Dr. Chopra covers macular mapping as well as diagnostic accuracy, repeatability and tracking of glaucoma over time.

Rob Brass, M.D. on How the RTVue OCT measures Keratoconus

Fri, 23 Oct 2009 00:00:00 GMT

Dr. Brass discusses how the Optovue RTVue measures keratoconus. Dr. Brass reviews how corneal thickness measurements as well as topography aid in diagnosis of keratoconus.

Georges Baikoff, M.D. on High Resolution Corneal OCT: Clinical Applications

Fri, 23 Oct 2009 00:00:00 GMT

Georges Baikoff, M.D. discusses several clinical applications of high resolution corneal OCT, including: corneal thickness, pachymetry mapping, keratoconus diagnosis, lasik flap measurement, corneal opacities, and DESK follow-up.

The TAN EndoGlideT Endothelial Insertion System

Wed, 14 Oct 2009 00:00:00 GMT

Corneal transplantation is undergoing a paradigm shift with the development of Endothelial Keratoplasty.

The main focus today is to reduce iatrogenic damage of donor endothelium caused by manipulation and insertion of the donor through a small incision, a difficult surgical task.

The EndoGlide(tm) is a device for surgeons to use which consistently delivers a donor lenticule through a small incision, with minimal endothelial loss, while making the insertion procedure relatively reliable and consistent, with the surgeon in full control of the donor at all stages of insertion.

The TAN EndoGlide(tm) System Consists of a preparation base, glide cartridge and a glide introducer.

Douglas D. Koch, M.D. on Corneal Power Calculations Using RTVue

Wed, 07 Oct 2009 00:00:00 GMT

Douglas D. Koch, M.D. describes the potential of the RTVue-CAM to determine corneal power measurements for normal, post-surgery, and pathological eyes.

Dr. Huang, MD, PhD on Corneal & Doppler Optical Coherence Tomography

Wed, 30 Sep 2009 00:00:00 GMT

Dr. Huang reviews a broad range of corneal, refractive, glaucoma, and retinal cases where Fourier domain OCT (FD-OCT) can be used for evaluation. Dr. Huang also reviews applications of Doppler FD-OCT to determine retinal blood flow.

Samuel Masket, MD Reviews Endophthalmitis Prevention

Fri, 29 May 2009 00:00:00 GMT

Devastating complications due to endophthalmitis can occur after seemingly uncomplicated eye surgery. Dr. Masket reviews four methods to consider for preventing endophthalmitis before, during, and after surgery. Special attention is given to the construction and maintenance of incisions for stability and to limit post-operative ingress of microbes.

George Waring IV, MD Recaps Femtosecond Laser Comparison Study

Thu, 28 May 2009 00:00:00 GMT

George Waring IV, MD reviews a study conducted with Daniel Durrie, MD comparing two femtosecond lasers: the Intralase FS60 and the Ziemer LDV. Relative benefits of the lasers were evaluated. Post operative clinical analysis showed no statistical differences between the two laser treatments. Dr. Waring IV covers the thorough evaluation for planarity and uniformity of the flaps as well as the electron microscopic evaluation for bed smoothness.

George Waring IV, MD is in private practice for cataract, lens and refractive surgery. He is also Clinical Assistant Professor of Ophthalmology, Emory University School of Medicine in Atlanta, GA.

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Glenn Cockerham, MD: Occult Eye Injury Following Combat Blast Exposure

Thu, 28 May 2009 00:00:00 GMT

Blasts that are sufficient to cause brain injury to a protected soldier are sufficient to cause occult ocular injuries. Many soldiers that are home from Iraq and Afghanistan have been exposed to such blasts and many have no visual complaints. Good visual acuity and a lack of symptoms can mask a range of problems such as retinal tears, traumatic glaucoma, choroidal ruptures and more. Dr. Cockerham discusses non-ophthalmic symptoms to look for in a patient, as well as how to refer patients who are found to have occult eye damage.

Randall Olson, MD Reviews the Causes and Prevention of TASS

Tue, 26 May 2009 00:00:00 GMT

Randall Olson, MD of the University of Utah John A. Moran Eye Center, talks about the causes and prevention of toxic anterior segment syndrome (TASS). Dr. Olson answers the question: "what can you do about it?" Dr. Olson covers specific examples and causes stemming from various breaks in protocol. Dr. Olson stresses using careful protocol in prevention of TASS. If TASS does occur, Dr. Olson recommends using careful review and step-by-step sleuthing of cases to find the breakdowns in protocol that caused the TASS.

Douglas Rhee, MD Covers Highlights of the 2009 ASCRS Glaucoma Day

Fri, 22 May 2009 00:00:00 GMT

Douglas Rhee, MD of the Massachusetts Eye and Ear Infirmary touches on the two biggest highlights of the 2009 ASCRS Glaucoma Day: the evidence-based approach for examining some of the newer surgical procedures in glaucoma, and the surgical complications video.

Dr. Rhee talks about some of the surgical options for the glaucoma patient, as well as laser procedures, and research in laser technology. Dr. Rhee also briefly reviews imaging modalities in diagnosis and tracking progression of glaucoma.

Daniel Chang, MD: Tips for Implementing Electronic Health Records

Thu, 21 May 2009 00:00:00 GMT

Daniel Chang, MD, of Empire Eye and Laser Center offers tips on where to start when implementing Electronic Health/Medical Records in your practice. Dr. Chang covers how to choose a system, who to turn to for help, and how to keep your system safely backed up.

ASCRS 2009: David Chang, MD Recaps the Binkhorst Lecture

Wed, 20 May 2009 00:00:00 GMT

Cataracts are the number one cause of blindness worldwide. There are more than 18 million people who are bilaterally blind from cataracts (using the 20/400 definition). Additionally, there is a critical shortage of ophthalmologists in the developing world. Dr. Chang highlights working model systems that successfully address these issues with low-tech solutions.

Dr. Chang also speaks about a recent white paper that addresses the usage of IOLs in the sulcus.

ASCRS 2009: Robert Melendez, MD Interviews Alan Crandall, MD, New President of ASCRS

Mon, 18 May 2009 00:00:00 GMT

Dr. Melendez and Dr. Crandall discuss examples of how young ophthalmologists can engage in lifelong learning, as well as ways to get involved with ASCRS and ophthalmology at large.

ASCRS 2009: Cristina Boggiano Offers Advice for Job Seeking Ophthalmologists

Wed, 22 Apr 2009 00:00:00 GMT

David Goldman, MD, interviews Cristina Boggiano, Founder of The Ophthalmic Associates about looking and recruiting for ophthalmic positions. Cristina offers key pointers and names several resources for those looking for employment as well as for those who are hiring.

The Ophthalmic Associates has specialized in placement of ophthalmic physicians and personnel for over 10 years.

Significance of Mature Abnormal Vessels in the Treatment of Wet AMD

Thu, 09 Apr 2009 00:00:00 GMT

To receive a free copy of this video click here

Through the use of 3D animation, clinical images, and expert commentary from a leading vitreoretinal specialist Mark S. Hughes, MD*, this video provides a comprehensive review of the progression of wet AMD, from angiogenesis to vessel stabilization. The video demonstrates that as vessels mature into established abnormal vessels they become less dependent on VEGF. Visudyne^® (verteporfin for injection) targets established abnormal vessels to help protect against vision loss due to wet AMD.

*Mark S. Hughes, MD, is a consultant to Novartis Pharmaceuticals Corporation. Dr. Hughes is a vitreoretinal specialist at the Ophthalmic Consultants of Boston and is affiliated with the Schepens Eye Research Institute of the Harvard Medical School.

Indication

Visudyne^® is indicated for the treatment of predominantly classic subfoveal choroidal neovascularization due to age-related macular degeneration, pathologic myopia or presumed ocular histoplasmosis.

Important Safety Information

Visudyne is contraindicated for patients with porphyria or known hypersensitivity to any component of Visudyne.

Infusion-related transient back pain occurred with Visudyne only. Verteporfin infusion induces temporary photosensitivity; patients should avoid exposure of skin and eyes to direct sunlight or bright indoor light for 5 days. To prevent extravasation, avoid fragile hand veins in favor of larger antecubital veins.

Severe vision decrease (≥4 lines) was reported within 7 days in 1% to 5% of patients. Partial recovery occurs in some patients. Do not re-treat these patients until vision completely recovers to pretreatment levels and potential benefits and risks of subsequent treatment are carefully weighed.

The most frequently reported adverse events (10%-30% incidence) were injection site reactions (including extravasation and rashes), blurred vision, decreased visual acuity, and visual field defects.

Please click here for full Prescribing Information

VSD-900160

Clinical Benefits of the RPS Adeno Detector

Thu, 12 Feb 2009 00:00:00 GMT

Dr. Robert Sambursky of Rapid Pathogen Screening describes the benefits of their point-of-care diagnostic devices in a conversation with Dr. Carlos Buznego.

The RPS Adeno Detector is a rapid immunochromatographic test for visual, qualitative in-vitro detection of adenoviral antigens (hexon protein) directly from human eye fluid. The hexon protein is shared across all 51 serotypes of adenovirus. The test is intended for use as an aid in the rapid differential diagnosis of acute adenoviral conjunctivitis.

The diagnosis of Adenovirus infection has historically been made clinically (with an accuracy of only 40-70%). The Adeno Detector has a sensitivity and specificity that rival that of confirmatory cell culture and PCR methods (sensitivity = 89%), specificity = 94%).

The clinical significance of the increased ability to diagnose adenoviral conjunctivitis is multi-fold.

preventing the spread of disease with early and accurate diagnosis
increasing the clinical vigilance around specific adenoviral morbidities
avoiding the over-prescription of antibiotics
reducing cost of treatment
diminishing the development of antibiotic associated allergies and toxicities

The true strength of this system may be that it is a CLIA-waved system. This enables it to be used by practically anyone in a clinical setting (primary care physicians, nurses, technicians).

Dr. Sambursky then demonstrates the use of the RPS Adeno Detector. It’s as simple to use as a pregnancy test and takes only 10 minutes to obtain a result. Reimbursement is via CPT code 87809QW and the cost of the each test is around thirteen dollars.

Comparison of SLO Microperimetry and Humphrey Field Analyzer in Detecting Visual Field Loss in Advanced Glaucoma

Tue, 10 Feb 2009 00:00:00 GMT

Stuart G. Coupland, PhD, of the University of Ottawa Eye Institute presents "Comparison of SLO Microperimetry and Humphrey Field Analyzer in Detecting Visual Field Loss in Advanced Glaucoma".

OPKO/OTI Spectral OCT SLO

Tue, 10 Feb 2009 00:00:00 GMT

Dr. Richard B. Rosen describes some of the advantages of the Spectral OCT SLO system in a series of case presentations.

Understanding Spectral OCT

Tue, 10 Feb 2009 00:00:00 GMT

Dr. Bruno Lumbroso of the Centro Oftalmologoico Mediterraneo in Rome, Italy, describes how the technology has challenged the clinician's ability to interpret the huge quantity of sometimes perplexing new data.

Microperimetry in the Decision Making Process in Management of Macular Diseases

Tue, 10 Feb 2009 00:00:00 GMT

Felix N. Sabates, MD, of the Univ. of Missouri, Department of Ophthalmology describes the importance of integrating microperimetry into your imaging algorithm for patient evaluation.

A New OCT-based Method for Predicting Visual Acuity in Patients with Macula Oedema

Tue, 10 Feb 2009 00:00:00 GMT

Professor John Marshall of St. Thomas's Hospital in London reviews the anatomy of cystoid macular edema (CME) and a novel method for comparing structure-function relationships.

Digital Imaging in ROP Screening: Telemedicine Around the Globe

Tue, 03 Feb 2009 00:00:00 GMT

This series of podium presentations from the recent World Ophthalmology Congress discusses the use of digital imaging in the screening of pre-term babies for retinopathy of prematurity (ROP). Retina specialists from across the globe describe their experiences with telemedicine networks enabled by digital image capture.

The advantages of digital images in ROP screening are multifold: First off, the images are portable. Qualified ophthalmic photographers at remote locations can submit images to a central reading center for interpretation by a seasoned pediatric retinologist who can then screen dozens babies in one day without leaving the office. This overcomes geographic limitations in accessing the best care possible. Additionally, one can archive these images for patient follow-ups or in medico-legal disputes.

Though binocular indirect ophthalmoscopy allows excellent visualization of the retina, documentation of the findings is typically sketched by hand and is prone to a great deal of subjectivity resulting in a high degree of intra- and inter-operator variability.

Winfried Amoaku, MD Outlines Retina Treatments in the UK

Tue, 27 Jan 2009 00:00:00 GMT

In an interview with retina specialist Sophie Bakri, MD of the Mayo Clinic, Dr. Winfried Amoaku discusses ophthalmology in the context of the UK's National Health System.

Treatments for macular degeneration in the UK: offering laser treatment for extrafoveal neovascular membrane. For subfoveal or juxtafoveal they offer PDT for predominantly classic lesions, and then the anti-VEGF treatments. Just as in the US, Lucentis is approved but Avastin is available off-label for some patients (based in financial constraints). Macugen is not considered cost-effective. Until NICE approved the use of Lucentis, many patients paid for the treatments out of pocket (either Avastin or Lucentis). Private sector vs. NHS treatments do differ because drugs are typically available considerably earlier in the private sector.

The process for drug approval in the UK: National Institute of Clinical Excellence (NICE) evaluates pharmaceutical candidates referred to them from the Department of Health. They then establish a committee to evaluate the drug. Approval can take from 3 months to 2 yrs (e.g., Lucentis and Macugen were 2 year approval). Many factors are weighed in approval including the final clinical use protocols. In ophthalmology, treatment of only one eye is sometimes deemed sufficient. An appeal processes exists to change the committees final decision however. Compromises are often required (e.g., Novartis example). The IVAN study is currently underway in the UK comparing Lucentis and Avastin (with 600 patients).

As Vice President of the Royal Academy of Ophthalmologists, it is Dr. Amoaku's responsibility to manage the scientific content of annual congresses and to aid in fundraising for ophthalmic research.

Carol Karp, MD on New Treatments in Ocular Surface Tumors

Tue, 27 Jan 2009 00:00:00 GMT

Carol L. Karp, MD describes the treatment of ocular surface tumors in an interview with David Goldman, MD. Ocular surface tumors can be put into three categories: pigmented, non-pigmented and lymphomas. Ocular squamous neoplasias (which used to be called CIN -- corneal and conjunctival intraepithelial neoplasia) is part of the spectrum of squamous cell carcinomas and are invasive whereas CIN is full thickness or partial thickness of the epithelium only. These tumors are almost always non-pigmented. Appearance varies: papillary, gelatinous, leukoplakic, opalescent if on cornea. Rose Bengal staining is very helpful in differential diagnosis. When there's a breakdown of the mucin layer of the eye, the keratin of the tumor stains. It can also demonstrate the margins of the lesion.

The decision to perform surgery is based on size and surgical risk (damage to limbus), and complexity of reconstruction. Another factor is that some patients prefer surgery. Other options are medical treatments. Mitomycin-C (MMC), 5-fluorouracil (5-FU), or Interferon (IFN).

Dr. Karp's personal preference is for IFNs because of their biology. IFNs are used systemically for leukemia and melanomas. Use in eye is off-label. Can be used as drops and is well tolerated. Compounded at 1M IU/mL. Dosed q.i.d. for 3 months of treatment is generally efficacious. Sub-conjunctival injection is another option - no compliance issues. Each injection is 3M IU. Side effects of the subconjunctival IFN injection can cause a flu-like malaise for the next 4 to 6 hrs. Injections are given once or twice a week.

Mitomycin-C is used in trabeculectomies and pterygium surgeries. In this setting, it is administered q.i.d. at either 0.02% or 0.04%. Punctal plugs used to protect lachrymal ducts. Used 7 to 14 days depending on how long the patient can stand the discomfort - epithelial toxicity. Once compounded, the solution is stable for only about two weeks with refrigeration. Several rounds of this may be necessary. It is effective but is really rough when compared to IFN.

5-FU, also used in glaucoma surgery, is another alkylating agent. More stabile than MMC, 5-FU is used similarly (q.i.d. for 7 to 14 days). Patrick Yeatts, MD suggests using 4 days of treatment, taking the rest of the month off, then cycling again. 5-FU seems to be somewhat less effective but causes less toxicity than MMC.

If a patient is on IFN and reaches a plateau, you could then try a course of MMC. Conversely, a patient on MMC can be switched to IFN if MMC is poorly tolerated. Dr. Karp often does a biopsy at the slit lamp to confirm the diagnosis. This is because not everything that looks like a CIN is a CIN: could be an amelonotic melanoma, or a sebaceous cell carcinoma. So if you're treating a patient clinically and there is little response to treatment, it could be one of these other diseases.

Dr. Karp then goes on to describe three cases in which successful resolution was demonstrated using MMC drops, IFN injections and topical IFN.

IFN is used to treat cervical intraepithelial neoplasia. This disease and conjunctival intraepithelial neoplasia have a lot of parallels: both are at transition zones between non keratinized epithelium, Langerhans cells immune vigilance, and HPV 16 and 18 have a role in disease.

Dr. Karp performs post-treatment biopsies on occasion to verify the absence of residual neoplastic cells.

Samuel C.Yiu, MD, PhD, Discusses Cornea Transplantation Surgery and Dry Eye

Tue, 27 Jan 2009 00:00:00 GMT

Dr. Yiu provides an update on a variety of anterior segment issues in a conversation with Dr. Brian Francis.

The DMEK procedure: DMEK = Descemet's membrane only, no stromal tissue. It is relatively new with few surgeons actually skilled in the technique. At Doheny, they've done nearly 200 cases. Tissue preparation for the DMEK is more challenging in that eye banks do not prepare the tissue in the same way they do donor corneas for DSEK. Penetrating keratoplasty with the IntraLase femtosecond lasers is being done at Doheny also (IEK, IntraLase Enabled Keratoplasty). In the first 9 cases they have done, the astigmatic changes compared to traditional corneal transplant is much smaller. This is because of the precision of the cut. IEK has the advantage of preparing donor and recipient tissues identically and allows for the tissue to be joined mechanically using a zigzag pattern, akin to an interlocking puzzle piece. Also reduces the time required for sutures to remain in the tissues. This allows for greater strength of the cornea once healed.

Dry Eye Therapy: Restasis (topical cyclosporine)has been the only option since 2004. However several new drugs are in the pipeline and offer some encouraging data. Dicrovazole, a p2-i2 agonist, affects the tear film by increasing production of mucin and oily layers of tear film. Another presented had dual action: lubricating and penetrate deep into epithelium for extended duration. Artificial lachrymal gland project: an implantable of live tissue on biocompatible scaffold to enable patients to secrete more tears. Azasite, azithromycin, may impact the Meibomian gland positively and offer some relief - more work needs to be done here.

Graft rejection in corneal transplant: Use of topical drugs has not been found to be efficacious. At Doheny, a more aggressive triple therapy approach is in use. They are also one of the sites evaluating the Lux Biosciences cyclosporine implant which offers sustained release for one year. Preliminary data are encouraging. Topical avastin may aid in reduction of neovascularization, implicated in corneal graft rejection.

LeeJee H. Suh, MD Reviews DSEK Complication Rates

Tue, 27 Jan 2009 00:00:00 GMT

Dr. Suh outlines her recent publication on DSEK complications -- Complications of Descemet's stripping with automated endothelial keratoplasty: survey of 118 eyes at One Institute.

Most common complication is dislocations, but re-bubbling or repositioning the graft is a viable option. Even so, a significant number of the relocated grafts fail (stay edematous). One of the factors in graft failure is the loss of endothelial cells. Other complications, cystoid macular edema, retinal detachment (if previous procedures had been done), suprachoroidal hemorrhage, epithelial ingrowth, graft rejection (most of which resolved with medical treatment). In one aphakic patient, one day post-op, the surgeons were unable to find the graft, but on ultrasound it was found in the posterior pole.

DSEK hints: Graft insertion has to be as atraumatic as possible so limit the manipulation. Pupillary block is always a risk so keep a large air bubble to keep the graft attached for the first ten minutes then reduce. Use of cycloplegics may also be a good idea whereas some choose peripheral iridotomy. Graft insertion innovations will be the main thing driving success rates. Even with the complications listed, most of which can be corrected, DSEK is still a better approach that full thickness PK. Everyone is looking forward to long term data on endothelial cell counts in these grafts.

Vikas Chopra, MD, Discusses Methods for Characterizing the RNFL in Glaucoma

Thu, 15 Jan 2009 00:00:00 GMT

The structure of the optic nerve indicates its function. This fits with the definition of glaucoma: a progressive optic neuropathy with functional vision loss. EMGT and OHTS studies both show that early detection and treatment can preserve vision.

Stereo photography is the gold standard for characterizing the optic nerve head, but only 50% of ophthalmologists routinely use this method. Visual field evaluation is of less importance since this occurs late in the disease process.

Imaging technologies that can actually automate the diagnosis for you are the best. GDx-VCC, HRT, OCT. Recently Fourier Domain (FD-OCT) has gained a lot of attention. These systems have about 65 times the speed at twice the resolution when compared to time-domain OCT. This greatly enhances the ability to visualize and identify anomalies in the structure of the optic nerve and the nerve fiber layer.

FD-OCT is particularly good at identifying all of the retinal layers allowing retinal layer segmentation. The three innermost layers of the retina (ganglion cell layer, nerve fiber layer, and the inner plexiform layer) can be visualized and changes identified.

The Advanced Imaging Glaucoma Study is the first to review all of the newest technologies vs. the time-tested methods of fundus photographs and visual field testing. AIGS is a multicenter, 5 yr, prospective, longitudinal trial, looking at glaucomatous changes at 6 month intervals.

Early results show that macular degradation is measurable in glaucoma as evidenced by thinner inner retinal layers. This corresponds to a visual field defect and is this predictive of functional loss? The correlation is good, but not as good as the circumpapillary retinal nerve fiber layer since this measurement takes data from more of the retina. Combining these data improves the diagnostic ability of these tests.

Monitoring these patients over time will help discern whether these changes reflect these early stage glaucomatous progression.

FD-OCT allows for Doppler measurement of retinal blood flow. This may afford the ability to detect NTG pts. Several studies have shown that ocular perfusion, particularly in patients with low diastolic pressures, are at increased risk of developing glaucoma. So Doppler OCT around the optic nerve can be of use in determining retinal blood flow. Adaptive Optics with OCT should enable the visualization structures in even greater detail by compensating for aberrations.

Dr. Cedric Francois Discusses the Complement C3 Inhibitor POT-4 for AMD

Thu, 15 Jan 2009 00:00:00 GMT

Cedric Francois MD, PhD, President/CEO of Potentia Pharmaceuticals describes his company's novel anti-AMD compound (POT-4) in a conversation with Dr. Sophie Bakri.

After trying many approaches, complement inhibition was viewed as being the best way to modulate the activity of macrophages in the back of the eye. The role of macrophages in the chronic inflammatory disease process is well understood and has been shown to be a factor in dry Macular Degeneration. The role of complement in macular degeneration was established in 2005 as the first breakthrough discovery resulting directly from the human genome project.

Compstatin is a potent complement inhibitor first characterized by John D. Lambris, PhD at the University of Pennsylvania 12 years ago. Compstatin is a small peptide with favorable properties of being able to be formulated in a sustained release configuration and also worked on C3 protein of the complement cascade. POT-4 is a much more active version of the original compound. Early work shows that the safety of POT-4 is really quite good.

The ASaP trial, "assessment of safety of POT-4", is a phase I, randomized, dose-escalation trial at 6 sites. Pts with disciform scars and are no longer candidates for Avastin and Lucentis. Pharmacokinetic evaluation of POT-4 is showing that expected dosing targets have been achieved and importantly that the sustained presence of the drug is being demonstrated. In a non-human primate model (at 4 dosing levels) sustained release was demonstrated for as long as nine months.

The next clinical study will focus on geographic atrophy as an end point, with wet-form AMD in patients who are not responsive to Lucentis or who have developed geographic atrophy in spite of years of therapy. Preventing the exudative process is the objective.

David F. Williams, MD, MBA Outlines the Goals of the ASRS

Mon, 12 Jan 2009 00:00:00 GMT

David Williams, MD, President of the American Society of Retinal Specialists, discusses the ASRS with retinal surgeon Dr. Sophie Bakri. Dr. Williams reviews the history of the ASRS and its formation from what was then the Vitreous Society. Dr. Williams charts his involvement with the ASRS beginning with his first meeting years ago in Paris. In 1997, he was asked to participate in the board of directors for the ASRS and became an at large member. Membership in the ASRS is open to ophthalmologists who have completed a retina fellowship and are practicing in this field.

The ASRS has continued to evolve by including input from younger members resulting in improvements the society; for example, the new "fellow-in-training" membership category, the young physicians section, and "women in retina". The new features of the annual meeting include instructional courses and the film festival. Outside the meeting the ASRS provides a practice management seminar, the website www.asrs.org, and production of "The Retina Times".

The ASRS maintains a healthy relationship with industry with the understanding that they share a mutual goal: the health of patients. But recently, the spotlight has been on relationships between industry and individual physicians (and physician organizations such as the ASRS). Concern over industry incentives and perks to inappropriately sway prescribing behavior and affect the content of CME programs have been pervasive. But industry and physicians have common interests: providing the best possible care to patients. The ASRS will continue to engage industry but do so in a very transparent manner. Ultimately, the goal would be to be for the ASRS to become financially self-sufficient.

Internationally, the ASRS and EVRS (the European equivalent) have collaborated on the Con-Retina festival, the largest meeting of retina specialist ever held. Other combined international events are in the works.

Preparations are underway for the 2009 ASRS from September 30 to October 4th in New York City. It will be a combined event with the Macula Society, the Retina Society, and the ASRS. Dr. Williams also describes the changes to the ASRS website now being made by Tom Chang, MD, the former editor of the Retina Times. Gaurav Shah, MD, is now the Retina Times editor.

With more than 2000 members, the ASRS, is the primary representative of Retina Specialists and is recognized as such by AAO, industry, regulators, and by payers. Still, the evolution of the ASRS has drawn largely from ad-hoc initiatives. But now the ASRS is embarking on a strategic planning effort.

Dr. David Tse Describes the FCI Integrated Orbital Tissue Expander

Fri, 19 Dec 2008 00:00:00 GMT

Dr. David Tse explains the benefits of FCI Ophthalmics’ new Integrated Orbital Tissue Expander in a conversation with Dr. Timothy McCulley (UCSF).

The integrated orbital tissue expander (OTE), designed by Dr. David Tse (US patent #6582465), consists of a flexible “balloon/expander” held in place by a titanium fixation plate that is anchored to the lateral orbital wall by screws. A slotted arm attached to the fixation plate, extends through a slot that is formed within the OTE. The OTE will be self-centered in the expanding socket as the orbit grows. A 30 gauge disposable hypodermic needle connected to a 1cc disposable syringe filled with sterile saline is inserted into the OTE through an injection port. The injection track seals upon the removal of the needle. Inflation of the OTE will effect pressure on the orbit of the patient.

The OTE is used in the treatment of:

congenital anophthalmia
congenital microphthalmia
acquired anophthalmia from cases such as early ocular tumors or trauma

Benefits of the OTE:

Implanted using normal oculoplastic surgical techniques
Does not require multiple surgeries
Multiple fixation areas on bone plate; allows for fixation point change as child grows
Can easily be inflated or deflated without surgery
Inflation and deflation can be controlled by the doctor
Can be removed and replaced. There are two adjustments required periodically:
- Inflation of the globe to stimulate bone growth
- Confirmation of self-centering

The infant is carefully followed by the surgeon who decides the adjustment intervals required to facilitate the desired result of facial symmetry. The recommended use for the OTE is one year, but optimal removal time is at the surgeon’s discretion.

AAO 2008: Anti-VEGF Therapy in Glaucoma with Farnaz Memarzadeh, MD

Fri, 21 Nov 2008 00:00:00 GMT

Farnaz Memarzadeh, MD, describes anti-VEGF therapy in glaucoma in an interview with Dr. Brian Francis at the 2008 AAO meeting in Atlanta. Dr. Memarzadeh reviews some of the indications where anti-VEGF therapy may be used: neovascular glaucoma (NVG), as an adjunct to trabeculectomy in place of MMC or 5-FU, or as a rescue therapy in the event of a failed trabeculectomy.

Intravitreal injection of Avastin or Lucentis causes very rapid regression of the neovascularization of the iris and angle, thereby preventing angle closure and further progression. This suggests that if you can get to these patients early enough anti-VEGF treatments may work well.

The first randomized trial of the use of Lucentis in glaucoma is now is underway at Doheny. This phase 1 trial with 30 NVG patients combines Lucentis with standard therapies such as PRP and tube-shunt surgeries. Outcomes measured are intraocular pressures, iris neovascularization, evaluation of the posterior pole, angle neovascularization, and macular edema.

In POAG, Lucentis could be used in "rescuing" failing trabeculectomies (with subconjunctival injections). Using a rabbit model (which is particularly sensitive), Dr. Memarzadeh investigated the use of sub-conjunctival injections of Avastin (vs. 5-FU) in conjunction with trabeculectomy as primary therapy. Using Avastin, she and her colleagues found that bleb survival doubled compared to sham treated (BSS), or 5-FU treated. A poster was presented at AAO on this work that featured data from graded histology slides showing that the Avastin group had the least amount of scar tissue formation. Future comparative work may evaluate intracameral injection vs. subconjunctival vs. intravitreal injections.

Intraoperative use of VEGF inhibitors concurrent with trabeculectomy (in humans) has been done and was recently presented at ARVO.

Dr. Uday Devgan Shares Pearls for MICS and the Management of Sub-optimal Surgical Outcomes

Fri, 21 Nov 2008 00:00:00 GMT

Uday Devgan, MD shares pearls for converting to microincisional phacoemulsification in an interview with Dr. David Goldman. Microincisional cataract surgery (MICS) is becoming very popular and may soon become the predominant method for performing this surgery. Phacoemulsification systems have better fluidics and software to allow for the use of normal settings, yet the incisions are smaller. To some extent this results from improved engineering of the phaco tip and tubing. For 2.0mm phaco everything basically remains the same.

Capsulorrhexis can sometimes be a challenge, but thin capsulorrhexis forceps usually make this task much easier, obviating the need for a cystotome needle. Dr. Devgan has designed his own set of capsulorrhexis forceps that are cross-action, thin armed, and laser marked so that the size of the rrhexis can be measured. Single piece acrylic lenses can still be passed through 2.0 to 2.2 mm incisions. Most lenses work. For the right lens however, Dr. Devgan would be willing to use a 3.0mm incision. Wound integrity at 3mm is still quite good provided the phaco is done at around 2.2 and the incision expanded for lens implant. From the patient perspective, smaller incisions do not affect the postop burning and foreign body sensation.

Most surgeons are used to making astigmatically neutral incisions, so from this point of view, 2.8 to 2.0mm is largely the same. A small incision that seals well is hopefully of a lesser risk in developing endophthalmitis. Dr. Devgan then weighs the benefits of subsequent astigmatism correction methods, limbal relaxing incisions, toric IOLs, refractive procedures. LRI if <1.5d. Any bigger, use a toric IOL. But in cases where the patient demands an accommodating IOL, a refractive procedure on top of the IOL may be required.

Dr. Devgan then tackles the difficult decisions required when a patient is dissatisfied postoperatively. Does one offer a piggy back lens, a lens exchange, or refractive procedure? Glare and halos associated with a multi-focal IOL usually result in lens-exchange. If a small degree of power + or - is required, then refractive procedures are the way to go. But if a large degree of correction is required, as would be the case in a prior RK patient, the calculations are much more complicated, and the cornea is too weak for LASIK. This may be the ideal case for a piggy-back lens. What is key to remember is NOT to implant acrylic lens over an existing acrylic lens. Inter-lenticular opacification may result and is refractory to YAG laser treatment. The solution is to use either silicone or collamer lens in the sulcus. Also, the piggy-back lens (placed anterior to the existing lens) always has to be a 3-piece lens because the haptics are finer and less apt to scrape the back of the iris and cause pigment dispersion and chronic uveitis.

Albert J. Augustin, MD, On Combination Therapy Against Choroidal Neovascularization (CNV)

Fri, 21 Nov 2008 00:00:00 GMT

Dr. Albert J. Augustin from the University of Mainz in Germany discusses treatment strategies against choroidal neovascularization (CNV) in a conversation with retina specialist, Dr. Sophie Bakri. Dr. Augustine defines the combination therapy parameters currently in use at his institution to combat CNV.

His version of triple therapy consists of a modified photodynamic therapy (with reduced light dose of 73 seconds from 80) followed by an intravitreal injection of dexamethasone (800 mcg) and Avastin (2mg). In lesions that are somewhat fibrotic, 1mg of triamcinolone is added. They no longer do a limited vitrectomy to compensate for drug volume.

Early results show that visual acuity increase is maintained (~2.5 lines at 79 weeks). Retreatment with a complete triple cycle was needed in 7 patients. 30 patients received a second Avastin injection during the follow-up period. Treatment guidelines allow for monotherapy reimbursement, therefore combination therapy is not an option for many patients who rely on the public medical system.

The future of treatment for macular degeneration seems to be focusing on various monotherapies, but combination therapy is inevitable with anti-VEGF (anti-cytokine agent), anti-inflammatories, and other agents that directly combat CNV.

AAO 2008: Bradley Randleman, MD, Describes A New Ectasia Risk Assessment Model

Wed, 19 Nov 2008 00:00:00 GMT

Dr. J. Bradley Randleman discusses a new risk-score model for assessing post-LASIK ectasia risk in an interview with refractive editor Dr. David Goldman. Five risk factors were identified: 1.) topographic abnormalities, 2.) low residual stromal bed thickness, 3.) young age, 4.) low preoperative corneal thickness, and 5.) myopia. Dr. Randleman then comments on thin-flap, or SBK, in the context of the tensile strength of the various layers of the cornea. In treating ectasia patients, gas permeable contact lenses alone have shown promise. Trials evaluating corneal cross-linking with riboflavin and UVA are underway at ten sites in the US including Emory. Dr. Randleman reviews some of the preliminary results. Combining various ectasia treatments CCR, intracorneal ring segments, and even PRK on top of the flap is discussed. Achieving spectacle independence is possible in many cases.

AAO 2008: Dr. Audrey Talley-Rostov Shares Tips on Anterior Segment Procedures

Mon, 17 Nov 2008 00:00:00 GMT

Dr. Audrey Talley-Rostov describes some of the latest trends in Cataract, Refractive, and Corneal procedures in an interview with Ryan Alfonso, MPH, of OphthalmologyWeb. Dr. Talley-Rostov describes the trend toward the use of accommodating IOLs like the Crystalens HD. She then shares tips on the preoperative counseling of presbyopic IOL patients. Dr. Talley-Rostov then defines a variety of options are available to remedy both quality and amount of vision in patients with post-operative complaints. Femtosecond assisted laser keratoplasty using the Intralase system in corneal transplantation has also been used in her practice. Matching the donor and recipient tissue geometry with the zig-zag pattern has resulted in far better outcomes (20/25 in one case, 4 months post-op). She also describes her use of intrastromal corneal ring segments in the treatment of pellucid marginal degeneration, keratoconus, post-LASIK ectasia, and even post-RK ectasia.

Advances in Fourier/Spectral Domain OCT Technology with the Optovue RTVue

Thu, 30 Oct 2008 00:00:00 GMT

OphthalmologyWeb presents a series of talks on the Optovue RTVue recorded at the 2008 World Ophthalmology Congress (WOC) in Hong Kong.

Diagnostic Instrument Integration

Tue, 28 Oct 2008 00:00:00 GMT

In this presentation, Dr. David Kirschen reviews the compelling reasons why he chose to purchase a digital fundus camera for his practice. The advantages of the Kowa nonmyd a-D 5MEGA with VK-2 Digital Imaging System are outlined. Images and data can be easily integrated into existing EMR systems. It allows you to deliver the best possible care to your patients by enhancing diagnostic sensitivity. It is also of great financial and legal benefit to your practice.

Measuring Corneal SA and Choosing the Right Aspheric IOL

Tue, 28 Oct 2008 00:00:00 GMT

Jack Holladay, M.D., describes how the Tecnis IOL is designed to compensate for the naturally occurring spherical aberration of the cornea.

Flap Curl: Easily Remedied

Thu, 16 Oct 2008 00:00:00 GMT

Dr. Cory Lessner from the Millennium Laser Eye Centers in Florida shares this surgical pearl in the management of a postoperative complication in a LASIK patient. "This patient's flap edge (6-8 o'clock) had flipped under within an hour of leaving the laser center. As such, no epithelium had grown onto the stromal bed. By utilizing the 27G canula tip with a small amount of BSS followed by the merocel smoothing technique, I was able to save this patient a trip back to the laser suite."

Micro Striae: A LASIK Complication with a Simple Solution

Thu, 16 Oct 2008 00:00:00 GMT

Dr. Cory Lessner from the Millennium Laser Eye Centers in Florida shares this surgical pearl in the postoperative management of LASIK patients with micro striae. "When the folds become too significant, it is usually best to gently refloat the flap with a short stream of BSS or a 27G canula, then employ the smoothing technique."

Microgap Smoothing

Thu, 16 Oct 2008 00:00:00 GMT

Dr. Cory Lessner from the Millennium Laser Eye Centers in Florida shares this surgical pearl. "Here is another example of microgap smoothing with a wet Merocel. This maneuver is easy to perform and should be used to eliminate any separation at the completion of these procedures. Note that as I become more comfortable that the flap will remain in position, my strokes with the merocel move more from the tip to the base."

Fiber Removal without Flap Displacement

Thu, 16 Oct 2008 00:00:00 GMT

Dr. Cory Lessner from the Millennium Laser Eye Centers in Florida shares his solution to a postoperative complication in a LASIK patient. "Isolated fibers and particles are typically easy to remove from under the flap with forceps. Here, an extraxial fiber is removed without disturbing the position of the flap using an angled Kelman-McPherson forcep."

Early Identification of Epithelial Ingrowth

Thu, 16 Oct 2008 00:00:00 GMT

Dr. Cory Lessner from the Millennium Laser Eye Centers in Florida shares this surgical pearl in the treatment of a this rare and difficult postoperative complication. "Unimpeded EI will continue to migrate and after several weeks will involute in areas, undergo apoptosis and take on the typical textbook appearance we are all familiar with. Early identification, therefore, gives us the unique opportunity to treat EI at the slit lamp."

The Medennium SmartPLUG™: Clinical Utility and Practice Issues

Wed, 08 Oct 2008 00:00:00 GMT

This video reviews many of the key benefits of using the Medennium SmartPLUG in your practice:

Physical characteristics of the innovative thermosensitive, hydrophobic acrylic polymer
Contents of the starter pack with insurance billing information and patient education brochures
Punctal occlusion reimbursement issues
Review of diagnostic procedures that would indicate the use of punctum plugs (Zone Quick)
How to properly consent your patients
Procedural review including insertion and removal of the SmartPLUG

The Medennium SmartPLUG™: A Patient's Guide to Dry Eye Treatment

Wed, 08 Oct 2008 00:00:00 GMT

If you suffer from the dryness, burning, itching, or excessive tearing caused by dry eye; effective long-term relief is now available without the inconvenience and expense of daily eye drops or ointments.

SmartPLUG from Medennium is an innovative device used to occlude the "punctum" or tear duct, and conserve the eye's natural tears. SmartPLUG is designed to fit a range of punctum sizes. Made of a flexible thermosensitive acrylic material, SmartPLUG adjusts to the exact shape and size of the punctum.

WOC 2008: Dr. Eli Chang on Orbital Decompression for Thyroid Eye Disease

Thu, 17 Jul 2008 00:00:00 GMT

Dr. Eli Chang discusses surgical options for thyroid eye disease cosmesis in a conversation with OphthalmologyWeb glaucoma editor, Dr. Brian Francis. Dr. Chang reviews his presentation, delivered at the 2008 World Ophthalmology Congress in Hong Kong, entitled "Decompression Surgery for Thyroid Eye Disease". Over the past 20 years, the indications for this surgery have grown beyond globe subluxation, lagopthalmos, and compressive optic neuropathy (CON). Decompression is now frequently undertaken for rehabilitative and cosmetic reasons in the treatment of disfiguring exophthalmos. The more commonly used transcaruncular, endoscopic and transantral decompression procedures carry too great a risk of post-op diplopia -- nearly 38%. Dr. Chang describes a new decompression technique developed with Dr. Alfio Piva: "lateral wall with excision of greater sphenoid wing" (LW+GSW). Using an eyelid crease incision, this "ab externo" approach drills from the temporal fossa inward, vs. from the orbit outward in other procedures. Bone is removed following the temporal lobe dura into the greater sphenoid wing to the superior orbital fissure. The lateral wall is then removed from posterior to anterior. In the first series of 65 orbits, the incidence of postoperative diplopia was only 3%.

Dr. Uday Devgan Discusses The Future of Refractive Surgery Practice

Wed, 16 Jul 2008 00:00:00 GMT

Dr. Devgan discusses the future of refractive and cataract practice in a conversation with refractive editor Dr. David Goldman. The boundary between "refractive" and "cataract" surgery is growing smaller, becoming part of a continuum of a comprehensive refractive surgery practice. LASIK patients will eventually become presbyopic patients, and cataract patients are expecting LASIK-like outcomes. Therefore, Dr. Devgan believes in offering a full spectrum of refractive surgery using a variety of techniques. PRK, corneal inlays, phakic IOLs (in front or behind the iris), RLE, accommodating lenses, multi-focal lenses. Patients then know that you've offered them the appropriate treatment, not simply the one you know how to do. Surgical pearls in combined procedures are discussed at length. Age and refractive error allow him to gauge generally what the options are for a patient. From that point, discussing outcomes expectations with the patient is key. Dr. Devgan then discusses resident education at UCLA and his involvement in ensuring the highest quality educational opportunities are afforded.

Trends in Ophthalmic Microbiology - Perspectives from Dr. Francis Mah

Wed, 16 Jul 2008 00:00:00 GMT

In a conversation with Dr. Parag Majmudar, Dr. Francis Mah discusses the current thinking in ocular microbiology in the cataract and refractive setting. Methicillin-resistant S. aureus (MRSA) is now the leading cause of post-LASIK infection. Data from an ASCRS cornea clinical committee survey in 2001, found that 48% post-lasik infections were caused by atypical mycobacteria. With use of moxifloxacin and gatifloxacin, those rates have gone down. By 2004, 60% of infections were S. aureus and less than 5% mycobacteria. This year's data show that MRSA is the #1 culprit. This follows the trend seen throughout ophthalmology; methicillin resistance being seen more frequently in endophthalmitis and keratitis. Dr. Mah suggests that standard of care should be that LASIK and cataract patients are treated for pre-existing dry eye. Lid draping is key since the normal flora is often the source of contamination. Povidone-iodine 5% can be applied to the eyes of cataract patients. Avoid povidone-iodine in the eyes of LASIK patients, but apply it generously to the lids and lashes. Meticulous sterile surgical technique is key. For LASIK, use the 4th generation fluoroquinolones. IQUIX (1.5% levofloxacin) has shown excellent penetration into ocular tissues. Dr. Mah then outlines his own recommendations for post-op dosing of both LASIK and cataract patients. He then discusses the endophthalmitis delay in clear corneal incisions, suggesting that longer use of anti-infectives may be indicated. Another controversy is the use of intra-cameral anti-infectives. This was highlighted in several recent European studies. Dr. Mah currently does not use intra-cameral antibiotics for prophylaxis though he does see the logic. His concern is of the risk of toxic anterior segment syndrome (TASS) and that long-term safety studies on the use of intra-cameral injections have not been done.

Carlos Buznego, MD on Presbyopic IOL Procedures

Wed, 16 Jul 2008 00:00:00 GMT

William Trattler, MD and Carlos Buznego, MD discuss presbyopic IOL technology in cataract surgery. Patient selection for these lenses involves assessing patient needs and conducting a variety of preop tests: super pinhole (potential acuity meter), corneal topography to rule out irregular astigmatism, macular OCT to rule out epiretinal membrane. Dr. Buznego has developed a mnemonic for his approach R-E-S-T-O-R: Retina (use NSAIDs to prevent cystoid macular edema), Emmetropia (hit the target), aStigmatism (look at pre and postop topography), Tears (dry eye is often a problem in variable vision), Opacified posterior capsule (lower the threshold for posterior YAG capsulotomy relative to traditional monofocal patients), Repeat (the fellow eye, these lenses often work best in a binocular fashion).

The Future of Refractive Surgery and Presbyopic IOLs with Jason Stahl, M.D.

Wed, 16 Jul 2008 00:00:00 GMT

Dr. Jason Stahl reviews the highlights of the 2008 ASCRS meeting in a conversation with Dr. Parag Majmudar. The global nature of the meeting allows for an international sharing of experience with these lenses. Though surgeons are interested in the technology, few have adopted the technology in their practice. Femtosecond laser LASIK flap creation, Intralase and others, is another hot area, especially in the creation of very thin flaps. This results in better corneal stability. Dr. Stahl explains his research: a contra-lateral study where the Intralase and Ziemer systems are tested in the same patient. Early results show that both produce predictable and accurate flap creation. Thin planar flaps are essential to corneal biomechanical stability, preferable to microkeratome. Sub-Bowman's Keratomileusis (SBK) vs. surface ablation. SBK biomechanical stability approaches that of surface ablation techniques. Dr. Stahl then reviews the nature of his practice which emphasizes academics and research: evaluation of new technologies - lasers, pharmacologic agents, IOLs, etc. The future of refractive surgery is presbyopic IOLs. Cataract and Refractive surgical disciplines are fusing to the point where surgeons really need to master both to meet patient expectations. Baby boom generation (fee for service patients) doesn't want to wait for cataract procedures. High expectations. Refractive Lens Exchange with presbyopic IOLs is really a four-in-one proposition: stabilizing vision (no presbyopia), obviating cataracts, correcting refractive error, good near vision, good distance vision. In the future, Dr. Stahl believes refractive error will by corrected primarily in a lens-based approach vs. LASIK, especially as the technology of accommodating IOLs improves.

Reducing DSEK Complications with Dr. Francis Price

Wed, 16 Jul 2008 00:00:00 GMT

Dr. Francis Price describes the secrets behind his very low DSEK dislocation rate in a conversation with OphthalmologyWeb contributing editor Dr. Clark Springs. Some of the pearls: Incision size matters (4 to 5 mm). Minimizing donor tissue damage using Ogawa forceps. Dr. Busen's "glider" funnel introducer. Clear corneal incisions are optimal with forceps technique vs. scleral tunnel. This may not be the case with the funnel technique. Anterior chamber maintenance with BSS and 23 gauge needle during the Descemet's stripping. Recently been using VSDs but the drawbacks are that an I/A tip is in the field and residual VSDs may interfere with donor adhesion. Vision Blue (DORC) is a good contrast agent. Air is perhaps optimal during the stripping of Descemet's. AC maintenance once the donor tissue is in place is not used, except with the Busen glide is being used. Precut vs. Surgeon cut comparison - same in his study of 40 cases (20 each). Typically though, they cut their own tissue. 9mm donor is their preferred size. Anesthesia techniques are also reviewed. Dr. Price also outlines techniques to assure donor tissue adherence and defines his approach for patients with concomitant cataracts. Management of patients with anterior chamber IOLs is reviewed as is trabeculectomy. Eyebank statistics - demographics of transplants: in 2005 EK was 4% of transplants performed. In 2006, 16% of grafts were for EK. 2007 = 37%, showing that DSEK is rapidly increasing. Anterior lamellar keratoplasties will also be increasing in the future as long term data on PK become known.

Hot Topics in Cornea and Presbyopic IOLs with Dr. Audrey Talley-Rostov

Wed, 16 Jul 2008 00:00:00 GMT

Dr. Talley-Rostov outlines the hot-topics of the 2008 ASCRS meeting: The beginning of large multi-center study evaluating corneal cross-linking with riboflavin (CCR), corneal topography and the detection of post-LASIK ectasia. Intracorneal ring segments can be helpful in the treatment of ectasia, keratoconus, pellucid ectasia or post-RK ectasia -- hopefully delaying the necessity of corneal transplant in these patients. Pitfalls of presbyopic IOLs: her presentation stressed the importance of being very familiar with the spectrum of multifocal and accommodating lens options. Dr. Talley-Rostov then characterizes her practice in which they recently began femtosecond-assisted keratoplasty with the zig-zag format. DSEK combined with cataract she'll do the DSEK afterwards.

Dr. Uday Devgan on Reimbursement Issues and Cataract Patient Counseling

Wed, 16 Jul 2008 00:00:00 GMT

Refractive editor Dr. David Goldman continues a conversation with Dr. Uday Devgan regarding CMS reimbursement in cataract procedures. The normal fee for cataract has decreased to the point where we will have a two-tiered system. Costs of lenses, and continued fee-cuts result in a widening gap. Spectacle independence among baby boomers is a chief concern. As such, premium IOLs will always be popular. IOL exchange pearls are discussed. The two then have a discussion on how best to counsel patients in this era of rapidly evolving options in cataract surgery.

Dr. Parag Majmudar on the Impact of Collagen Crosslinking and DMEK

Wed, 16 Jul 2008 00:00:00 GMT

Dr. Parag Majmudar reviews highlights of the 2008 ASCRS meeting in a discussion with Dr. William Trattler. Corneal collagen cross-linking with riboflavin + UVA shows great potential for the treatment of ectasia and keratoconus. This has tremendous potential to treat early stage keratoconus patients so that they may be eligible for refractive procedures. Endothelial keratoplasty is another hot-topic having gone from DLEK to DSEK and possible moving to DMEK (Descemet's membrane only) in the future. Initially, his DSEK procedure followed that of Francis Price, MD, with preparation of donor tissue. Dr. Majmudar has recently switched to using pre-cut donor tissue, but finds that tissue thickness standardization is still an issue. Femtosecond technology may remedy this soon. Has used 60/40 fold, tri-fold, and glides for insertion of donor tissue into the anterior chamber. The goal is the preservation of the endothelial cell layer and ensuring better visual outcomes. DMEK is another hot topic. Pioneered by Garrit Melles, MD, DMEK is based on the idea that stromal dissection isn't required, allowing you to implant only Descemet's membrane into the anterior chamber. Using non-air gases such as octafluoropropane (C3F8), or sulfur hexafluoride (SF6) may aid in prevention of graft dislocation.

Dr. Abhay Vasavada's Experience as a Cataract Surgeon in India

Tue, 15 Jul 2008 00:00:00 GMT

In a conversation with Dr. Parag Majmudar, Dr. Abhay Vasavada shares what he learned at the 2008 ASCRS meeting. Pediatric: congentical cataract and microophthalmos management. Small incision coaxial phacoemulsification: <2.0mm is threat to incision integrity, risk of induced astigmatism and endopthalmitis. Dr. Vasavada currently favors micro-coaxial vs. bimanual phacoemulsification. He supports the use of intra-cameral antibiotics, stresses the importance of proper draping procedure with povidone. He is using Vigamox now, but had used vancomycin in the past. In thousands of surgeries, he hasn't had an endophthalmitis case. The nature of his practice and educational structure of his institution in India is also discussed in detail.

Mark Packer, MD Reviews Highlights and New Technologies of ASCRS 2008

Tue, 15 Jul 2008 00:00:00 GMT

Dr. Mark Packer discusses ASCRS 2008 highlights in a conversation with Parag Majmudar, MD. The "Around the world in 90 minutes" session encompassed major geographies and their respective cataract societies. Fostered a discussion on aspheric IOLs, correcting for aberration and lens selection. New technologies: Ed Sarver and associates VOLCT software -- takes the output from any topographer and give you Zernike coefficient for the cornea. Then match the corneal aberration and compensate with the IOL to net zero. Another aberrometer you can use is the Tracey iTrace. It incorporates a topographer, so it's essentially like the Isis topographer but also functions as an aberrometer. Intra-operative aberrometry by WaveTech in the aphakic state. Eric Donnenfeld MD, presented on the correction of corneal astigmatism with toric IOLs and LRI based on intra-operative wavefront abberometry. Preoperative IOL calculations with an IOLmaster or keratometer with Holladay II formula is today the best available method. Dr. Packer then describes the use of intra-operative wavefront aberrometry in a clinical study. TruVision, another company Dr. Packer is involved with, uses an HD digital microscope to project 3D images in cataract surgery. The ergonomic freedom at the operating table frees you from being tethered to the microscope. For routine cases this can be helpful, but in more difficult cases, where there is a lot of arcus, dense cataract, or vitreous hemorrhage, standard methods are preferable. At ASCRS, a course entitled "Cataract Surgery presented in 3D HD" was delivered to an audience wearing polarized glasses to view the 3D projected images in an actual case.

Dry Eye Pearls with Dr. Jodi Luchs

Mon, 14 Jul 2008 00:00:00 GMT

In an interview with Dr. William Trattler, Jodi Luchs, M.D. discusses the diagnosis and management of dry eye. A clear tear-film and well hydrated eye are critical for successful outcomes in any kind of refractive or cataract surgery. Assessing signs and symptoms of tear insufficiency, Meibomian gland disease. The biggest challenge is the asymptomatic patient that may still have a tear film instability - by staining pattern, tear break-up time (TBUT), etc. Lid margin assessment: erythema, collarettes in lid margin and lashes, qualitative evaluation of Meibomian gland expression, glandular inflammation. TBUT can be rapid in regular dry-eye and in dry eye with poor tear-film quality. Inflammatory tear film from aqueous insufficiency. However, Meibomian gland disease, oil insufficiency, can still result in rapid TBUT. Dr Luchs then outlines a treatment plan for aqueous insufficiency patients, and Meibomian gland dysfunction patients. Artificial tears work well for most patients but does not treat the underlying pathophysiology. Restasis has worked quite well in the stabilization of inflammatory dry eye, improving aqueous flow and stabilizing the tear film. Topical steroids have a role in inflammatory dry eye; low dose for a few weeks, helps pts tolerate Restasis. Azasite, a topical azithromycin, can stabilize inflammation at the lid margins to improve the secretions of the Meibomian glands. Warm compresses and gentle lid massage is a mainstay treatment as well. There is also a role for combining Restasis and Azasite. Punctal plugs are very necessary as an adjunct to post refractive patients. Often Restasis and/or Azasite treatment may precede using a punctal plug.

Phakic IOLs with John Vukich, M.D.

Mon, 14 Jul 2008 00:00:00 GMT

In a conversation with Dr. David Goldman, refractive editor of OphthalmologyWeb, Dr. John Vukich reviews the latest thinking in phakic IOL implantation. He also discusses some of the issues reviewed at ASCRS cornea day sessions: Endothelial cell density review in angle supported lenses. Safety of the various lenses. Design - distance from cornea. Dr. Vukich then describes patient selection criteria for phakic IOLs vs. LASIK: topography, corneal thickness. 4-6 D range done, but typically over 8D. Lowest power available is -3D. As opposed to LASIK, phakic IOL risk is independant of "dose". At all levels of surgery, the procedure is the same, and so is the risk, regardless of corrective power. Astigmatic patients can still benefit from phakic IOLs when coupled with LRIs, or perhaps a surface ablation. Phakic IOLs have enjoyed double digit growth year/year for 7 consecutive years.

Dr. Sonia Yoo on Femtosecond Lasers in Refractive Surgery

Mon, 14 Jul 2008 00:00:00 GMT

Sonia Yoo MD, discusses femtosecond laser technology with retina editor Dr. David Goldman. Versus a standard microkeratome, a femtosecond laser is more apt to suffer epithelial breakthrough. This is handled by increasing flap thickness. Second pass is possible in the event of suction loss only in certain circumstances. Enhancements can be done with femtosecond flaps (only 4 year data available). Recutting a fresh side-cut may be done to minimize epithelial ingrowth risk. The lamellar cut isn't necessary in most cases. Other applications of the femtosecond laser: anterior lamellar keratoplasty. Full-thickness penetrating keratoplasty. Femtosecond PK allows for precise incisions and customized shapes to enhance patient outcomes.

Dr. Stephen Lane on the use of Prophylactic Intracameral Antibiotics in Cataract Surgery

Mon, 14 Jul 2008 00:00:00 GMT

Noted cataract surgeon, Dr. Stephen Lane discusses intracameral antibiotic use in cataract patients for the prophylaxis of endophthalmitis in a conversation with Dr. David Goldman. Dr. Lane reviews recent European data on cefuroxime in detail. Fourth generation fluoroquinolones are very popular in the US and used in most cases. Vigamox (moxifloxacin), preservative free, has the potential to be used intracamerally. Two recent studies (Dr. Steve Arshinoff, Canada, and Dr. Cesar Espiritu, Philippines) show no adverse effects. This was the groundwork for a US study undertaken with Drs. Stephen Lane, Sam Maskett, and Robert Osher. 0.01cc Vigamox used in 60 patients vs. BSS. Safety shown, efficacy will need a more powered study(>20k pts). Dr. Lane then describes the use of intracameral antibiotics in his own cataract practice.

Dr. Terrence O'Brien on TASS and Fungal Keratitis

Mon, 14 Jul 2008 00:00:00 GMT

In a conversation with Dr. Parag Majmudar, Dr. Terry O'Brien discusses current issues in ocular microbiology. Toxic Anterior Segment Syndrome (TASS) causation and differential diagnosis vs. endophthalmitis. Residual debris or viscoelastic on surgical instruments can cause an inflammatory reaction which can resemble endophthalmitis. Early endophthalmitis is different from TASS in several key measures: often with TASS there is no pain, non-reactive pupil, elevation of IOP, and blurred vision in association with significant corneal edema beyond what one would normally expect with phacoemulsification. Combating TASS is simple. Clean surgical instruments sufficiently. An option is to increase the inventory of surgical instruments in your surgery center. This allows staff ample time to prepare instruments. Recent epidemic fungal keratitis cases in contact lens wearers have involved Fusarium oxysporum and solani. The contact lens case, the solution, and the lenses themselves, need to be viewed as a mini-ecosystem. Acanthamoeba keratitis also on the rise in contact lens patients. The popularity of class 4 silicone hydrogel lenses that are stiffer materials may lead to micro-trauma of the epithelium, then the biocides that are taken up by the material are released onto the ocular surface creating punctate keratopathies which may open the door to Acanthamoeba and other non-bacterial pathogens. Switching to daily-ware disposable lenses, though costly, would provide one solution to some of these infections.

Microincisional Phaco Pearls from Dr. Elizabeth Davis

Fri, 11 Jul 2008 00:00:00 GMT

In a conversation with Dr. David Goldman, Dr. Elizabeth Davis outlines recent improvements in microincisional coaxial phacoemulsification and shares her wisdom on phaco techniques. The trend is toward decreasing incision size. This is a result of better viscoelastics (VSDs), antibiotics, NSAIDs, steroids, and advancements in foldable IOLs. Adoption of bi-axial phaco in the US was slow for a host of reasons. The move toward coaxial-MICS: no real technique change is required. The sub 2.0 coaxial phaco fluidics enhancements have allowed for better followability and control, reduced phaco energy, while allowing chamber stability. Fitting the IOL through the sub 2.0 incision is still a challenge. Making a new incision may be the solution: it seals better and reduces astigmatic change (less than 0.25D change). Dr. Davis then reviews her 1.8mm technique and her patient outcomes. Now uses Stellaris system and supra-capsular approach with a venturi mode and 600mm mercury. Systems that allow for MICS are adaptable to all techniques and all surgeons. New lenses that may fit through a 1.8 (such as the Akreos) may be available in the US in 6 months to a year.

Dr. Paolo Vinciguerra Describes the European Experience in Corneal Cross-linking with Riboflavin (CCR) and UVA

Thu, 10 Jul 2008 00:00:00 GMT

Dr. Paolo Vinciguerra explains the current state of the research on CCR (corneal cross-linking with riboflavin + UVA) in an interview with Dr. Carlos Buznego. Dr. Vinciguerra and his team in Italy have conducted several studies to evaluate the immediate and long-term effects of CCR in the treatment of keratoconus patients. Using the latest topography systems (Galilei, Pentacam), wavefront mapping systems, ORA, pachymetry and IOP, it was found that flattening of the cornea was immediate and continued to improve out to two years of follow-up. Post-LASIK ectasia in a patient population of ten eyes, with a 12-month follow up, has shown stabilization of disease and, again, improvement with time. Dr. Vinciguerra describes the optimized treatment procedure in detail; epithelial stripping, pilocarpine, 30 min. riboflavin soak, UVA application (6 x 5 min.), bandage contact lens during re-epithilialization.

Dr. Karl Stonecipher Shares Tips on Lowering Enhancement Rates in LASIK

Wed, 09 Jul 2008 00:00:00 GMT

Dr. Karl Stonecipher shares techniques for lowering enhancement rates in laser vision correction in an interview with Dr. William Trattler. Some key points are: carefully collecting your data and evaluating it vs. the latest nomograms can enable you to continually improve patient outcomes. One such nomogram system has been developed by Jack Holladay and Guy Kezirian and is called "Refractive Surgery Consultant". The "DataLink" system is a newer version of this. It is an advanced data registry, outcomes analysis and optimized nomogram generation system for many of the top refractive lasers. The system accounts for surgeon-to-surgeon variability, improvements in your surgical technique, and environmental conditions by evaluating your last 50 procedures. With increasing standardization of surgical theaters and techniques, soon very little adjustments will need to be made with individual treatments vs. the established nomograms.

Dr. Neal Sher Donates Refractive Procedures to Iraq War Troops

Wed, 09 Jul 2008 00:00:00 GMT

In an interview with Dr. Carlos Buznego, Dr. Neal Sher tells of his experiences providing pro bono refractive procedures to local National Guardsman and Army Reserves prior to their being deployed to active duty in the Iraq war. Providing these vision correction procedures has been particularly rewarding because, in many cases, it has contributed to the survival of combat troops, especially in night-time skirmishes Dr. Sher then describes his research documenting that the electrical field resulting from the operation of a variety of laser systems (SLT, VISX S4, argon, and YAG) does not interfere with several models of Medtronic pacemakers (ICDs, CRTs).

Dr. Eric Donnenfeld Shares Pearls for Premium IOL Practice

Tue, 08 Jul 2008 00:00:00 GMT

Dr. Eric Donnenfeld shares practice tips for premium IOL patients in a discussion with refractive editor Dr. David Goldman. Some key points: Premium IOL patients need premium care including premium pre-op evaluation. Careful attention needs to be given to the tear film, ocular surface (staining methods), and eyelid margins. His patients receive a full retinal exam including OCT and corneal topography mapping. This data may influence which IOL to use. Pearls on how to manage epiretinal membrane and cystoid macular edema risk in the premium or multi-focal IOL setting and the use of pre-op NSAIDs. Dry eye management in premium multi-focal IOL patients. Topical cyclosporin treatment regimen for multi-focal IOL patients. Research showing that preop use of Restasis in patients without dry-eye yields better quality of vision. Dr. Donnenfeld then discusses his research presented at this year's ASCRS meeting regarding argon laser iridoplasty for pupillary aperture centration relative to the lens axis (angle kappa) in multi-focal IOL patients. He then defines his "6 C's method" and the "5's" of the iridoplasty technique. In ReZoom lens patients iridoplasty has a role for the enhancement of near visual acuity by expanding the pupil thereby compensating 2.1mm central visual plane.

Video: Dr. Terry Kim Discusses Surgical Adhesives in the Context of Ophthalmic Surgery

Thu, 03 Jul 2008 00:00:00 GMT

Dr. Terry Kim provides his perspective on the 2008 ASCRS meeting in an interview with contributing editor, Dr. Parag Majmudar. High points of the meeting included the wet-labs, film festival and of course, "The Challenge Cup Series" combining education and entertainment. Dr. Kim describes the instructional courses on tissue adhesives that he's been developing with Chris Rapuano, David Ritterband, Herb Kaufman, Richard Copeland, David Hardten, and Sadeer Hannush. Applications of surgical adhesives in ophthalmic surgery include cyanoacrylates for corneal perforations and cataract incisions. Fibrin sealants are used in pterygium (conjunctival autografts and amniotic-membrane transplants) and LASIK complications such as epithelial ingrowth. All adhesives are used off-label, so Dr. Kim has been involved in creating a new adhesive specifically for ophthalmic use: HyperBranch's OcuSeal. Advantages are that it cross-links in 30 seconds, is easy to apply, and provides a microbial barrier as shown by Dr. Francis Mah.

Video: Arun Gulani, M.D. Discusses Corneoplastique™ at ASCRS 2008

Wed, 02 Jul 2008 00:00:00 GMT

Dr. Gulani shares his ASCRS meeting highlights in an interview with Dr. Parag Majmudar. At the top of his list were corneal cross-linking with riboflavin and UVA, freezing the cornea after PRK, and combining LASIK with multifocal IOLs. Dr. Gulani outlines his Corneoplastique technique, designed to reverse LASIK scarring. Dr. Gulani then explains his "5S" systematized approach behind the corneoplastique method: sight (restoration), site (central or peripheral cornea), strength (thinning as in ectasia or thickening as in pseudophakic bullous keratopathy and epikeratophakia), shape (irregular shape from previous refractive procedure, infection or trauma), and structure (entire ocular anatomy).

Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK): Techniques, Tips & Ways to Prevent Dislocation

Tue, 01 Jul 2008 00:00:00 GMT

Endothelial keratoplasty has developed at a rapid and exciting rate for the last 6 years. Although the DSEK and DSEAK method of endothelial keratoplasty is technically easier than its predecessor, DLEK, prevention of dislocation and primary graft failure have emerged as the primary challenges. In this video we present our method of performing DSEAK including the use of viscoelastic, optosol, stromal scraping, surface stroking and air bubble time, and give tips on the technique, care of the donor tissue and ways to prevent donor dislocation. We also present cases that illustrate the rapid and improved visual recovery seen in the DSAEK method of endothelial keratoplasty.

DSEK Pearls from Mark Terry, M.D.

Wed, 28 May 2008 00:00:00 GMT

Dr. Mark Terry gives his insights into the successful posterior lamellar translplantation procedure in an interview with Dr. Clark Springs. Dr. Terry describes why his group has the lowest endothelial graft dislocation rate and the lowest primary graft falure rate - the technique. A 5mm scleral-tunnel (vs. clear corneal) incision is done to enable the preservation of the endothelium - smaller confers no advantage. Long term follow-up at 8 yrs has shown that the grafts are clear but the endothelial cell counts have decreased to about 500 by 5 yrs, where it plateaues. No anterior chamber maintainer is needed. Fill the chamber with Healon 5, a visco-cohesive, until you implant the tissue. Healon does not contribute to dislocation. It does not appear in the interface. Proper tissue folding can obviate the need for marking the donor tissue - no need for an "S" mark. Graft diameter is matched to 8.5. Start at 8.0 of you're new to the technique. 40/60 fold and then inserted 60/40". - technique paper in press. Don't worry about chamber collapse. Use self sealing bevelled pericentisis sites vs. a 30 gauge needle. DSEK, DSAEK is compared to DLEK (stripping vs. dissection) physics of adhesion. Dr. Terry then discusses future trends in DSEK instrumentation such as inserters and the evolution of the DMEK procedure.

Dr. Kerry Solomon on ASCRS 2008 and LASIK Patient Satisfaction Data

Thu, 01 May 2008 00:00:00 GMT

Dr. Kerry Solomon shares his observations of this year's ASCRS meeting in Chicago: In the cataract setting, the proliferation of new IOL technologies and enhanced phacoemulsification systems has greatly improved patient outcomes. LASIK patients can expect better results than ever because of wavefront-guided ablations and femtosecond laser flap creation. Dr. Solomon also comments on refractive lens exchange and how the procedure complements current refractive practice. He discusses a recent meta-analysis of LASIK patient satisfaction data from 1993 to 2005 that supports the claim that greater than 95% of LASIK patients worldwide are happy with the procedure - higher than any other elective surgery. Dr. Solomon will be actively involved in a collaborative study between ASCRS, NEI, AAO and the FDA to evaluate patient quality of life post-LASIK.

Video: IFIS Pearls from David F. Chang, M.D.

Sun, 06 Apr 2008 00:00:00 GMT

Noted cataract surgeon Dr. David Chang describes recent changes in the management of intraoperative floppy-iris syndrome (IFIS) in an interview with refractive editor Dr. David Goldman. Dr. Chang summarizes the results of a new survey of ASCRS members on current practices in IFIS and describes his own strategies for the assessment of IFIS risk. He then offers a few surgical pearls regarding the use of pharmacologic agents, instrumentation and OVDs in treating these patients.

Dr. Eugene de Juan Describes Epi-Retinal Irradiation in wet-AMD

Thu, 13 Dec 2007 00:00:00 GMT

Noted retina specialist Eugene de Juan, M.D., discusses a novel system of controlling neovascularization in wet-AMD (NeoVista™) in an interview with Dr. Darius Moshfeghi. NeoVista is an intraocular device that locally delivers beta-radiation to the choroidal vascular bed of the retina during a minimally invasive surgical procedure. Dr. de Juan reviews the recent clinicial trial data and answers questions regarding the possible implications of this new treatment.

Session Highlights: Oculoplastics and Neuro-Ophthalmology

Mon, 12 Nov 2007 00:00:00 GMT

Dr. Wendy Lee, Oculoplastics Editor for OphthalmologyWeb asks Dr. Tim McCulley of UCSF about his key take-home messages from the neuro-ophthalmology and oculoplastics subspecialty presentations at this year's AAO meeting in New Orleans. Dr. McCulley also describes the ASOPRS sessions preceding the AAO. Non-invasive cosmetic procedures involving fillers such as autologous fat, laser treatments, and the use of botox are highlighted. Blepharoplasty techniques for Asian patients are presented in detail. Evisceration procedures and implant selection criteria are reviewed. He also outlines some of his own presentations around templar artery biopsies for giant cell arteritis in the Asian community near UCSF. In neuro-ophthalmology, Dr. McCulley discusses the presentations on the differential diagnosis and work up of unilateral disc edema. Another issue covered is the management of patients with normal examination and peri-ocular pain; etiology of orbital and lacrimal tumors like adenoid cystoid carcinoma, mechanisms such as peri-neural invasion vs. expansion, and the diagnostic utility in understanding the importance of quality and location of pain or paresthesia. Dr. McCulley suggests that the future of research in neuro-ophthalmology may lie in neuro-protection, preventing ganglion cell loss, in part funded by NIH grants for MS research.

Dr. Francis Mah Reviews Anti-Microbial Therapies at the 2007 AAO Meeting

Mon, 12 Nov 2007 00:00:00 GMT

Francis Mah, MD reviews his presentation regarding ocular immunology in a discussion with David Goldman, MD, Refractive Editor of OphthalmologyWeb. Dr. Mah comments on prophylactic intracameral antiobiotic use in the cataract setting and TASS complications from the inflammatory response. Dr. Mah suggested that the short and long term complications of anterior segment injections intra-operatively need to be further studied. Pre-operative antibiotic use is also discussed. Topical antibiotic use in cataract surgery is not supported by the literature. Even so 98% of surgeons, as reported by a recent ASCRS survey, use topical antibiotics prophylactically. Dr. Mah outlines his recommendations and reviews the new antimicrobial therapies launched at AAO: Azasite (azithromycin, 1%, Inspire) indication: bacterial conjunctivitis, and Iquix (levofloxacin 1.5%, Vistakon) indication: bacterial keratitis.

An Update on the Trabectome from the Inventors, George Baerveldt MD and Don Minckler MD

Mon, 12 Nov 2007 00:00:00 GMT

Dr. Brian Francis, Glaucoma Editor - OphthalmologyWeb, discusses the Trabectome as an alternative to goniotomy and trabeculotomy with Dr. George Baerveldt and Dr. Don Minckler. They explain the inception of the device, its design and function, the indications and the clinical data thus far. They also discuss use of the Trabectome in co-morbid cataract patients.

Cornea Specialist Ashley Behrens MD Reviews His Observations at the 2007 AAO Meeting

Mon, 12 Nov 2007 00:00:00 GMT

Ashley Behrens, MD of the Wilmer Eye Institute is interviewed at this years AAO meeting by OphthalmologyWeb's Refractive Editor David Goldman, MD. Dr. Behrens describes the meeting's highlights and his most important take home messages. Key among them are; the photodynamic cross-linking of corneal collagen with riboflavin and UVA for keratoconus patients and post-lasik ectasia cases, future implications of this technology, DSEK v. DLEK, DSEK complications such as dislocation, the use of glides and viscoelastics in the insertion of donor tissue, pterygium surgery techniques that result in reduced recurrence rates.

Dr. William Culbertson Presents Femtosecond Laser Pearls in Cornea Transplantion at the AAO 2007 Meeting

Mon, 12 Nov 2007 00:00:00 GMT

Corneal surgeon William Culbertson, MD of Bascom Palmer Eye Institute speaks with David Goldman, MD, refractive editor of OphthalmologyWeb. Dr. Culbertson describes the use of femtosecond lasers in penetrating keratoplasty to create an interlocking link between corneal donor graft tissue and recipient, eg, "top hat" shape. This year's AAO meeting also featured techniques for anterior lamellar keratoplasty with femtosecond lasers for the treatment of anterior corneal pathology, and the creation posterior lenticules for Descemet stripping endothelial keratoplasty procedures - DSEK. Tools for introducing the graft analogous to IOL injectors. Dr. Culbertson provides several surgical pearls for the DSEK procedure.

Refractive Lens Exchange Pearls from Dr. Uday Devgan

Mon, 12 Nov 2007 00:00:00 GMT

Uday Devgan, MD explores in detail his experience in refractive lens exchange (RLE) with OphthalmologyWeb retina editor David Goldman, MD. In private practice he does the gamut of refractive, lenticular and cataract procedures. He is also a clinical professor at UCLA where he trains residents on the use of both accommodating and multi-focal lenses. He describes many surgical caveats in presbyopic lens implants: Managing patent expectations in pre-operative consultations with younger vs. older patients. Management of astigmatism with LRIs in these patients. He describes the "bioptics" approach where the LASIK flap is cut contemporaneously with the lens exchange to allow for follow-up astigmatism correction via LASIK. Phaco pearls for non-cataract lenses including fluidics management and the use of viscoelastics in visco-mydriasis. "Epi-Sugar-caine" in the use treatment of Flowmax patients to counter floppy-iris syndrome. He also outlines the importance of patient education using your own practice's website.

Dr. Brian Francis Provides Updates on Glaucoma Treatments from AAO 2007

Mon, 12 Nov 2007 00:00:00 GMT

Dr. Brian Francis of the Doheny Eye Institute covers the glaucoma highlights at this year's AAO meeting in a discussion with Dr. Andrew Moshfeghi, Associate Retina Editor for OphthalmologyWeb. Some of Dr. Francis' key points from the sessions: research presented may expand indications for SLT, randomized trial data is now available for SLT vs. ALT at 3 yrs. Surgical techniques discussed at AAO: canaloplasty, trabectome, trabecular stent, and the gold microshunt. Trials: TVT (tube vs. trabeculectomy) study update. Current thoughts on IOP: diurnal pressure control and 24hr pressure monitoring devices. New drugs: Combigan's role may be similar to Cosopt long term. Mementine data was not presented at AAO. New technologies: Fourier domain OCT looks promising but no longitudinal data yet. Dr. Francis will be initiating a trial to evaluate intracameral Lucentis injections in the treatment of neo-vascular glaucoma (NVG).

AAO Lessons from the Perspective of a Glaucoma Specialist in Private Practice, Dr. Ben Mason

Mon, 12 Nov 2007 00:00:00 GMT

Dr. Ben Mason of the Wolfe Eye Center in Cedar Falls, Iowa discusses the glaucoma subspecialty day meetings at this year's AAO meeting with OphthalmologyWeb refractive surgery editor, David Goldman, MD. Some of the concepts covered are; the advantages of blebless surgery, TVT trial results, management of patients with concomitant cataract -- moving towards tube/phaco vs. trab/phaco. The use of the trabectome and endoscopic cyclo-photocoagulation (ECP). The launch of fixed-combined medications such as Combigan and its effect in patient compliance in the medical management of glaucoma. Current controversies such as the importance of target pressures, imaging modalities such as GDx, OCT, HRT, and their use in diagnostics and following progression. Future treatment regimes with lasers, pharmaceuticals, and surgeries

AAO Retina Subspecialty Day Highlights from Dr. Darius Moshfeghi

Sun, 11 Nov 2007 00:00:00 GMT

Dr. Darius Moshfeghi shares his key take-aways from the two retina subspecialty day sessions at this year's AAO meeting in New Orleans. Interviewed by Dr. John Kitchens, Associate Retina Editor for OphthalmologyWeb, the two have a lively discussion about the hot topics presented at the meeting. These include: anti-VEGF treatment strategies, monitoring retinal diseases with angiography and Fourier-domain OCT, the use of topical dorzolamide for juvenile retinoschisis and other indications. Increased rates of endophthalmitis with 25g vitrectomy, and the controversy over Genentech's limiting of Avastin's availability for retina specialists.

Dr. JoAnn Giaconi Shares Highlights from AAO Glaucoma Subspecialty

Sun, 11 Nov 2007 00:00:00 GMT

Dr. JoAnn Giaconi of the Jules Stein Eye Institute at UCLA describes her lessons learned at the 2007 AAO glaucoma subspecialty day in a conversation with OphthalmologyWeb oculplastics editor, Dr. Wendy Lee. Critical Issues were the summaries of ongoing clinical studies, the current thinking on the importance of IOP diagnostically, and surgical procedures. TVT study highlights: trabeculectomy vs. tube-shunt, showing equivalence in pressure control by 1yr, and that trab gp has a slightly higher failure rate, and that the tube gp needs a few additional pharma agents to get to the target pressure. Tubes are being used sooner in surgical management. One of the key clinical take home messages was that above all, the optic nerve head has to be imaged and followed diligently by GDx, HRT, OCT systems. Future trends suggested in this year's AAO meeting were largely in pharma. Newer prostaglandins and rock-inhibitors appear to be on the rise. The Women in Ophthalmology group, which Dr. Giaconi is involved in, was discussed briefly.

Douglas Katsev MD, Reviews the Cataract and Refractive Sessions at AAO

Sun, 11 Nov 2007 00:00:00 GMT

Dr. Douglas Katsev discusses what he gained from this year's AAO meeting with John Kitchens, MD, associate retina editor - OphthalmologyWeb. Dr. Katsev describes the use of multifocal lenses, ReZoom and Crystalens and ICL's in his own practice. He shares his experience in creating 100 micron flaps with the Intralase femtosecond laser. He also comments on the research around MMC use in PRK procedures. He addresses the question of why Lasik procedures have reached a plateau nationwide and what is necessary to overcome this, highlighting the use of LASIK by NASA and naval aviators. In his opinion, one of the main reasons for attending the AAO is to have discussions with peers to achieve consensus in optimal treatment procedures. Dr. Katsev reviews DSEK hints for clinical success. Instrumentation innovations he noted for corneal transplantation included 3-way graft folding and insertion devices allowing for the preservation of the endothelial layer.

IQUIX Launched at the 2007 AAO Meeting: Review of Santen's Portfolio

Sun, 11 Nov 2007 00:00:00 GMT

Adrienne Graves PhD, President and CEO of Santen, highlights their product portfolio from dry eye to retina and glaucoma (Alamast, Quixin, and Betimol). She is interviewed by Dr. Andrew Moshfeghi, Associate Retina Editor for OphthalmologyWeb, and Dr. David Goldman, Refractive Editor for OphthalmologyWeb. She discusses the launch of IQUIX (1.5% levofloxacin) at this year's AAO meeting in New Orleans. IQUIX is BAK-free, and has a much reduced dosing regimen compared to the other fluoroquinolones approved for corneal ulcer. Their novel rho-kinase (ROCK) inhibitor for the treatment of glaucoma is in phase I trials currently and was the subject of several presentations at the AAO showing promising results. For dry-eye, rivoglitazone (aka DE-101) is in phase II development.

Kowa's New VX-10 Mydriatic/Non-Mydriatic Digital Fundus Camera

Sun, 11 Nov 2007 00:00:00 GMT

Craig Ross, Vice President of Kowa Optimed, describes the essential elements of the Kowa VX-10 two-in-one digital fundus camera. This system allows you to do fluorescein angiograms, mydriatic and non-mydriatic color photography with one device. Ideal for a multi-specialty practice, the VX-10 allows for glaucoma screening, wide-field diabetic retinopathy screening, and basic fundus imaging. The VX-10 integrates into the Kowa VK-2 digital image management software system which allows you to view many different images side-by-side, and individual images in great detail.

Peribulbar Anesthesia for Vitreoretinal Surgery

Sat, 10 Nov 2007 00:00:00 GMT

Peribulbar Anesthesia has been described for cataract surgery, glaucoma surgery, and vitreoretinal surgery. It has distinct advantages over traditional retrobulbar anesthesia. These advantages include: decreased risk of retrobulbar hemorrhage and globe perforation, reduced amount of anesthesia, and a more rapid surgical preparatory time.

The Spec-Tac Disposable Lid Speculum Launched at AAO 2007

Sat, 10 Nov 2007 00:00:00 GMT

Barry Shafer, President of EnvisionEyes, discusses the creation of the Spec-Tac disposable eyelid speculum with Ryan Alfonso, MPH, managing editor of OphthalmologyWeb. This device prevents lids and lashes from interfering with a broad array of eye imaging modalities from anterior segment to posterior. The Spec-Tac was launched shortly before this year's academy meeting and received a great reception by ophthalmologists and technicians.

Launch of the EnvisionEyes Spec-Tac at the 2007 AAO Meeting

Sat, 10 Nov 2007 00:00:00 GMT

John Stephenson, President of EnvisionEyes, discusses the creation of the Spec-Tac disposable eyelid speculum with Ryan Alfonso, MPH, managing editor of OphthalmologyWeb. With Spec-Tac, lids and lashes are prevented from impeding visualization of ocular structures. Mr. Stephenson outlines the features of the Spec-Tac and its clinical use in a variety of settings.

Refractive Lens Exchange using Crystalens IOL

Fri, 09 Nov 2007 11:26:00 GMT

Uday Devgan, MD, FACS demonstrates crystalens insertion.