The comprehensive ophthalmologist program at the Hawaiian Eye meeting consisted of five days devoted to a broad range of topics:
cataract surgery,
glaucoma,
retina,
ocular surface disease, and
refractive surgery. A nice change this year was the inclusion of a CD in the program book containing handout views of the speakers’ talks, rather than a thick spiral bound paper syllabus. The majority of the presentations reviewed key topics confronting the general ophthalmologist, summarized findings from recent clinical trials, or updated the status of new technologies and procedures. Here are some of the highlights from the sessions:
Premium IOLs: This continues to be a hot topic that dominated the cataract section of the program. Specifically, the importance of optimizing the ocular surface (i.e., treating dry eye and blepharitis, and avoiding/minimizing BAK exposure), preventing CME with topical NSAIDs, and treating residual refractive error were reiterated. The speakers also stressed patient education, questionnaires, and relying on staff impressions for patient selection. Screening should include the use of vital dyes to accurately assess the ocular surface and topography and OCT to rule out corneal and macular abnormalities, respectively.
Presbyopic corneal inlay: Drs. Jack Holladay and Dan Durrie presented updates on this approach to the treatment of presbyopia. The Acufocus ultra thin corneal inlay (5 microns thick and 3.8 mm in diameter) utilizes a small aperture (1.6 mm) to increase depth of focus. It has been redesigned with more and smaller holes in the 5% transmission annulus to eliminate glare and halo.
Future IOL technology: Dr. Jay Pepose described new accommodating IOL designs including some of the more interesting approaches such as the FlexOptic lens, FluidVision lens, NuLens, LiquiLens, and SmartIOL.
Intraoperative floppy iris syndrome: Dr. David Chang reviewed the strategies for management of IFIS as well as trends regarding the alpha-blockers and cataract surgery among US surgeons. The vast majority of physicians who prescribe these medications are still unaware of the increased risk they pose for cataract surgery, so there is a need to further educate our colleagues.
IOL calculations after refractive surgery: This is another important issue that surgeons are encountering more frequently. Various formulas and methods for choosing the appropriate power IOL exist, and the faculty agreed that the IOL power should be selected based on consensus from multiple formulas.
Cataract complications: The video symposium is a very popular session, with standing room only. Cases presented this year included: posterior polar cataract (pearl
: no hydrodissection, or use very gentle viscodissection so as not to rupture the posterior capsule, which is sometimes unavoidable), change in postop refraction with Crystalens (pearl: look for anterior vaulting of the lens due to one (Z-syndrome) or both haptics, which can recur if the lens is merely repositioned), IOL exchange (pearl
: the MST forceps system allows access to all areas through small paracentesis incisions to aid in opening the capsule), minimally decentered multifocal IOL (pearl
: consider Dr. Eric Donnenfeld’s technique to shift the pupil with a sectoral laser iridoplasty consisting of 4 midperipheral spots @ 500 mW, 500 msec, 500 microns. Similarly, a 360 degree iridoplasty of 12 spots can be used to enlarge a small pupil that causes poor near vision with a refractive IOL), Malyugin ring (pearl
: rotate the subincisional loop slightly away from the wound so the phaco needle does not rub against it, and be careful during ring removal to prevent iridodialysis).
MRSA: The increasing prevalence of community acquired MRSA ocular infections is disturbing. MRSA is reported to be the causative organism in 28% of post-LASIK infections and 60% of endophthalmitis cases. Prophylaxis should be considered in high-risk patients (nursing home paitents, health care workers, etc). Antibiotic selection is important and more effective agents include trimethoprim, gentamycin, and vancomycin. Chloramphenicol, neosporin, and bacitracin may also be useful. The fluoroquinolones are not the best option, but besifloxacin, a new fluoroquinolone in development, has increased efficacy against MRSA.
Blepharitis: Azasite was discussed in various presentations as a welcomed advance in the management of this common condition. With antiinflammatory and antimicrobial activity, azithromycin is uniquely suited to treat blepharitis, and its once a day dosing regimen helps with patient compliance.
Adhesives: Dr. Terry Kim presented information about OcuSeal liquid ocular bandage, which creates a rapid, low profile barrier and is comfortable. Dr. Ralph Chu summarized the status of I-ZIP ocular bandage, which is well tolerated, persists for several days, and does not interfere with wound healing. Both tissue glues show promise for sealing corneal incisions.
Refractive surgery: Once again, speakers stressed the importance of optimizing the ocular surface both pre-and post-operatively. Ectasia prevention and management was addressed in a number of talks. Dr. Rex Hamilton briefly discussed Randleman’s point system for ectasia risk assessment, and then described 2 new preoperative indices he has been investigating (regional pachymetry index and posterior aconic elevation) that may facilitate early detection of keratoconus suspect corneas. Dr. Ronald Krueger presented an update on the technique of collagen crosslinking with riboflavin to stabilize the cornea. Surface ablation was also discussed as a procedure for retreatments, and Dr. Scott Barnes presented data from a military study, which showed that the type of lens used after PRK really does make a difference: the Oasys lens was more comfortable than the Acuvue 2 lens.