Eyeworld.org Articles

The debate around immediate sequential bilateral cataract surgery

Thu, 09 May 2013 15:04:31 -0400

Initial phaco quick chop in cataract surgery

Second chop in cataract surgery

Final quadrant removal in cataract surgery using phaco chop
Source (all): Brock Bakewell, MD

Immediate sequential bilateral cataract surgery (ISBCS) has elicited debate over how the advantage of operating on both eyes at the same time weighs against possible concerns and complications. When considering the benefits of both immediate sequential bilateral cataract surgery and delayed sequential bilateral cataract surgery, there are a number of factors to be examined. While addressing both eyes at the same time may be beneficial, there are also concerns for refractive results, safety, and a risk of infection. In addition, operating on both eyes at the same time is not routine in many places, with lack of reimbursement on the...

Addressing the most common cause of patient dissatisfaction

Thu, 09 May 2013 15:04:31 -0400

Tipperman's dictum #1: The No. 1 cause of patient dissatisfaction with advanced technology IOLs is residual refractive error.
Corollary to Tipperman's dictum #1: Correcting this refractive error leads to a happy patient.

I am always surprised at the number of patients I see in consultation for a "problem" with their advanced technology IOL who smile and respond, "That's great. That's how I want to see!" when I hold an appropriate trial lens up in front of their operated eye. Ophthalmologists have learned over time that even small residual refractive errors of 0.5 D can have a dramatic effect on patients' visual function.
Fortunately, as noted above, in these instances, correcting the residual refractive error resolves the problem.
There are multiple ways that surgeons can correct a residual refractive error after cataract surgery, which include optical correction, mini-RK, piggyback IOL, IOL exchange, or laser vision correction.
Optical...

Contact lens trials in (potential) premium IOL patients

Thu, 09 May 2013 15:04:31 -0400

Is it worth it?

A diagnostic test that can definitively determine which patients will be successful with premium lenses and which will not is still a pipedream. In the
interim, ophthalmologists use a variety of methods to attempt to determine which patients will be satisfied and which will end up unhappy. Multifocal contact lens trials can be useful in determining who will readily adapt to multifocal IOLs, but only if the patient has worn these types of lenses in the past and does not yet have a visually significant cataract.
"If a potential patient hasn't tried multifocal contact lenses, there's not much value in a clinical trial if they have a visually significant cataract as the blur from the cataract will make the vision unsatisfactory," said Richard Tipperman, MD, attending surgeon, Wills Eye Institute, Philadelphia...

Gender preferences with multifocal IOLs

Thu, 09 May 2013 15:04:31 -0400

Study finds gender differences in satisfaction levels with new multifocal IOLs

While the new generation of multifocal IOLs may bring high patient satisfaction rates, gender differences in satisfaction levels among the available lenses remain, according to a study by Magda Rau, MD, Augenklinik Cham, Germany.
About a decade ago, Dr. Rau and colleagues found a significant difference in the acceptance of multifocal IOLs between female and male cataract patients in a previous retrospective multifocal IOL study (1998-2003), she said. The results showed that the satisfaction of men and women was different after implantation with different multifocal IOLs. Although the explantation rate was low, it was interesting that there was a gender difference in the explantation of IOLs; explantation was performed in seven males and one female.
More recently, with a new generation of multifocal IOLs available, Dr. Rau wanted to see if there was still a difference in the acceptance...

HZO vaccine-recurrence link?

Thu, 09 May 2013 15:04:31 -0400

HZO neurotrophic keratopathy

HZO iridocyclitis
Source (all): Vincent de Luise, MD

A growing number of case reports have identified reactivation of ocular
inflammation from prior herpes zoster ophthalmicus following vaccination. Those reports have raised caution flags among some ophthalmologists.
In one of the most recent cases, Charles W. Hwang Jr. and colleagues reported in the April issue of Cornea a patient's reactivation of herpes zoster keratitis and worsening of neurotrophic keratopathy, keratouveitis, and keratoconjunctivitis sicca after vaccination with live attenuated herpes zoster vaccine (Zostavax, Merck, Whitehouse Station, N.J.).1
The 63-year-old male patient's herpes zoster keratouveitis and neurotrophic keratopathy was quiescent for three and a half years without medication...

Statins: A possible weapon in the fight against ocular inflammatory disease?

Thu, 09 May 2013 15:04:31 -0400

Larger clinical studies could help establish the effectiveness of statins to lower the
incidence of diseases like uveitis (pictured here).
Source: Manolette Roque, MD

Study shows promising potential protective effect

Could statins help stave off ocular inflammatory disease? It's too early to say for sure, but a recently published study found a trend toward a reduction in the risk of new disease development in patients who had used statins.
The study was published in the January issue of the Journal of Ophthalmic Inflammation and Infection.
Although the results did not reach statistical significance, investigators said that larger clinical studies could help establish the effectiveness of statins to lower the incidence of diseases like uveitis.
"It is too early at this point to make significant...

Studies indicate that outdoor time could minimize nearsightedness in children

Thu, 09 May 2013 15:04:31 -0400

Nearsightedness in children may be prevented or minimized by spending time outdoors, according to studies recently published in the May issue of Ophthalmology.
Two separate studies were conducted, one in Taiwan and another in Denmark. The first found that children's risk of nearsightedness was reduced when they were required to spend recess time outside. The Danish study was the first to show a direct correlation between seasonal fluctuations in daylight, eye growth and the rate of nearsightedness progression.
According to a press release on the studies, nearsightedness in
children can be corrected, but it can also lead to a more serious
condition with age or risks for other eye disorders and diseases.
The study in Taiwan compared myopia rates in children from one school from 2009-2010 to children at a control school. The first group of children participated in outdoor time for 80 minutes a day, while the control school's children were not required to...

Surgical options for pterygium evaluated

Thu, 09 May 2013 15:04:31 -0400

A preoperative photo of a pterygium

Postop photo of a different eye at one week after pterygium removal with autologous conjunctival graft and 10-0 vicryl suture
Source (all): W. Barry Lee, MD

Doctors employ many different surgical options to treat pterygium, both
primary and recurring. But which option is best? At this year's ASCRS Winter Update meeting, Clara Chan, MD, clinical lecturer, Department of Ophthalmology, University of Toronto, discussed pearls and pitfalls when dealing with pterygium. Citing information about specific procedures, her preferences, and a recent American Academy of Ophthalmology
report, Dr. Chan went into detail about the options for treating pterygium. EyeWorld followed up with Dr. Chan, as well as other doctors who worked on the report from AAO.

AAO's look...

What's on the horizon for MIGS?

Thu, 09 May 2013 15:04:31 -0400

The Hydrus device implanted in Schlemm's canal
Source: Ivantis

The CyPass device in a patient's eye
Source: Transcend Medical

More devices, multiple devices, and improved techniques are giving surgeons numerous treatment options
In the U.S., few microinvasive glaucoma surgery (MIGS) techniques are currently approved—just the iStent (Glaukos, Laguna Hills, Calif.) and the Trabectome (NeoMedix, Tustin, Calif.). Others are on their way, but are likely two to three years or more from regulatory approval. Studies and interim results from ongoing studies seem to suggest all the MIGS devices work well to reduce intraocular pressure (IOP), but there is limited data available or emerging to address how efficacious these devices might be without concurrent cataract surgery.
MIGS are ab interno procedures/...

Glaucoma surgery practice patterns changing

Thu, 09 May 2013 15:04:31 -0400

Slit lamp photograph shows a tube implanted in a glaucomatous eye.
Source: Manishi A. Desai, MD

Slit lamp photograph of trabeculectomy surgery, showing the site of filtration
Source: Manishi A. Desai, MD

With use of trabeculectomy and tube shunt surgery changing, surgical
practice patterns appear to be shifting
The glaucoma surgical treatment paradigm has been shifting for a number of years, as surveys of physicians and Medicare data have shown, with trabeculectomy appearing not as popular as it once was, tubes slightly increasing in use, and microinvasive glaucoma surgery (MIGS) and ab externo procedures possibly gaining ground.
The most recent published data on the use of trabeculectomy and tube shunts, specifically, is from 2008. Manishi A. Desai, MD, Department...

AqueSys glaucoma implant offers new way to bypass outflow obstructions and lower pressure

Thu, 09 May 2013 15:04:31 -0400

The AqueSys inserter

The 6-mm AqueSys implant is positioned next to an Ahmed Glaucoma Valve (New World Medical)

Anterior segment optical coherence tomography shows the soft AqueSys implant
conforming to the tissue in a human eye

Microscopic pictures from a side view of implant versions with water column present at inner lumen
Source (all): AqueSys

Gary J.L. Foster, MD, Fort Collins, Colorado, explains to Joshua Young, MD,
how he decides which patient needs combined or MIGS procedures and
who needs just phaco alone.
Go to ewreplay.org/
ASCRS2013/
saturday or scan the QR code above to view the video.

The device operates in the subconjunctival space and is...

Secrets of success to beginning with the iStent

Thu, 09 May 2013 15:04:31 -0400

Understanding the anatomy of the anterior chamber is one of the keys for practitioners new to using the iStent.
Source: Chris M. Calcaterra

David F. Chang, MD, discusses with Josh Young, MD, his experience with implanting the iStent device and offers some inplantation tips for the beginner. Go to
ewreplay.org/
ASCRS2013/
saturday or scan the QR code above to view the video.

Fresh pearls from new users
Since its launch in August 2012, the iStent (Glaukos, Laguna Hills, Calif.) has been rapidly adding new users to the fold. Like everything else, the first few tries with this device, slated for implantation in mild to moderate glaucoma patients who are undergoing cataract surgery, may seem daunting to a novice...

Tips from an old hand

Thu, 09 May 2013 15:04:31 -0400

Steven D. Vold, MD, Fayetteville, Ark., an iStent clinical investigator,
offered a few tips for new users.
• Try inducing a little hypotony to draw some blood reflux into the canal. "That way you can easily identify Schlemm's canal and prominent collector channels, especially in lightly pigmented eyes," he said. "Injecting viscoelastic into the anterior chamber may facilitate visualization of key angle structures as well." Also, he finds gently depressing the wound will allow some blood reflux to take place.
• Before going into surgery, try carefully describing the trabecular meshwork and the findings of the angle. "I always write little descriptive words about that," Dr. Vold said. "That way when you go in, there are no surprises."
• When inserting the iStent, try coming in at an approximately 15- to 20-degree angle approach. "I enter on the anterior side of the pigmented trabecular meshwork near one of...

Prostaglandin enters preservative-free zone

Thu, 09 May 2013 15:04:31 -0400

For eyes with compromised surfaces, like this one stained with lissamine green,
anecdotal reports show that even one drop of preserved medication may be enough to tip them over the edge.
Source: Robert J. Noecker, MD

Prescribing prostaglandins for glaucoma patients has taken on a new dimension. It's no longer simply a matter of deciding between brand name and generic medications. Practitioners these days have a new type of medication in this prostaglandin class to consider—the preservative-free drug Zioptan (tafluprost ophthalmic solution 0.0015%, Merck, Whitehouse Station, N.J.). Since February 2012 when Zioptan won FDA approval, this new option has given practitioners another tool to wield for glaucoma patients.
Zioptan has joined the ranks of other classes of glaucoma drugs
with non-preserved...

Monthly Pulse Keeping a Pulse on Ophthalmology Poll size: 190

Thu, 09 May 2013 15:04:31 -0400

The EyeWorld Monthly Pulse survey for May focused on glaucoma challenges, including microinvasive glaucoma surgery, or MIGS.
A slight majority of respondents (54%) remain concerned about the efficacy of MIGS procedures and cite that as their biggest challenge in beginning to use MIGS. Meanwhile, 25.9% thought that it would be a big step into unchartered territory since they don't currently perform glaucoma surgery.
In question 2, 60.7% said they don't wish to use Trabectome and cataract surgery. Many (41.4%) also believed that cataract surgery alone would help a patient whose IOP is 22 mm Hg on max meds with early visual field change.
Finally, most responders (68%) agreed that only head-to-head testing will determine which would lower IOP better—a device bypassing the trabecular meshwork or...

Book shares adventures in mission work

Thu, 09 May 2013 15:04:31 -0400

Dr. Simjee operates on a patient in Ghana.
Source: Aisha Simjee, MD

Aisha Simjee, MD, had 12 corneas in a box. She had hand-carried the cornea transplants, donated by Tissue Banks International, to Armenia. There, she would assist with ophthalmic volunteer work, using the corneas in waiting recipients.
After carrying the box throughout the journey, including a stop in Switzerland, she disembarked from the plane.
In Armenia, customs officials were confused. She said they were unsure what to do with her and her box of eyes. But the inevitable conclusion seemed to be that they would hold her for some time, putting the eyes in danger of losing their viability. When officials stepped out of the room, leaving her alone with the corneas, Dr. Simjee took action.
She...

Battle-scarred nation East Timor now battles eye disease

Thu, 09 May 2013 15:04:31 -0400

Phones, water, and roads may not work, but eyecare initiatives do
Calling Timor-Leste, or East Timor, is like calling every other nation with one main difference: After dialing the country code, you pray.
That's because there's often no getting through with any reasonable connection to many phones in Timor-Leste.
"Telco Systems here is … developing," said Laura Cleary, former program manager, The Fred Hollows Foundation New Zealand, via a Skype chat after a series of failed phone call attempts.
Ms. Cleary, who lives in Timor-Leste, had few illusions about what she was in for when arriving in 2008 in the middle of the rainy season. Assassination attempts on the president and prime minister occurred days before her first visit. This was a country recovering from a recent history of illegal executions and starvation...

ISBCS: The elephant in the (U.S. cataract) room

Thu, 09 May 2013 15:04:31 -0400

According to Prof. Claoué the falling incidence of endophthalmitis to approximately 1 in 2,000 makes the risk of simultaneous bilateral endophthalmitis approximately 1 in 4 million, or 1 case every 24 months if all cases of cataract surgery (assumed to be 2 million a year) in the U.S. were undertaken as ISBCS. Source: Nick Mamalis, MD

Yes, there is a society of bilateral cataract surgeons. And yes, they
advocate for immediate sequential
bilateral cataract surgery (ISBCS). As a profession, ophthalmologists have always been heretics, proposing radical ideas that shake up the status quo. Each crazy idea has caused us to reconsider what is comfortably familiar.
The deep controversy over intraocular lenses gave birth to a splinter group that became ASCRS. And what about the other crazy ideas like outpatient surgery, sutureless incisions,...

Final session of ASCRS meeting addresses best papers

Thu, 09 May 2013 15:04:31 -0400

Boris E. Malyugin, MD, David F. Chang, MD, Reay H. Brown, MD, Ronald Yeoh, MD, Bonnie An Henderson, MD, Elizabeth M. Hofmeister, MD, and Eric D. Donnenfeld, MD, served as panelists for the "Hot Off the Press" session.
Source: EyeWorld

In the final session of the ASCRS•ASOA Symposium & Congress in San Francisco, EyeWorld editorial board members joined together for "Hot off the Press," where presenters discussed some of the best papers of the meeting and panelists weighed in on the topics and technologies addressed in the papers. David F. Chang, MD, Los Altos, Calif., moderated the session, with Reay H. Brown, MD, Atlanta, Bonnie An Henderson, MD, Boston, Eric D. Donnenfeld, MD, Long Island, N.Y., Ronald Yeoh, MD, Singapore, and Elizabeth M. Hofmeister, MD, San Diego, serving as panelists. Presenting the papers...

Is glaucoma becoming a surgical disease?

Thu, 09 May 2013 15:04:31 -0400

At the ASCRS•ASOA Symposium & Congress this year Eric Donnenfeld, MD, the new ASCRS president, said that the most exciting area in ophthalmology is glaucoma. But lest glaucoma specialists be overcome with unexpected love, he added that it was something he never expected to say.
Dr. Donnenfeld's comments highlight both the optimism surrounding new developments in glaucoma as well as the surprise at the level of enthusiasm. Signs of the rise of glaucoma were all around the recent ASCRS meeting. Glaucoma Day had a banner year with a new record for attendance. There were more glaucoma papers presented than ever before. An EyeWorld symposium on the iStent (Glaukos, Laguna Hills, Calif.) had 600 attendees. All the ASCRS symposia dealing with glaucoma had full audiences.
The main reasons for the surge of interest in glaucoma are microinvasive glaucoma surgery (MIGS) and the use of cataract surgery to lower eye pressure. Both of these have brought comprehensive ophthalmologists...

In The Journal Of Cataract & Refractive Surgery May 2013

Thu, 09 May 2013 15:04:31 -0400

Visual outcome of cataract surgery
Mats Lundström, MD, Peter Barry, FRCS, Ype Henry, MD, Paul Rosen, FRCS, Ulf Stenevi, MD
In this study, investigators used data from the European Registry of Quality Outcomes for Cataract and Refractive Surgery database to evaluate visual results following cataract surgery in 15 European countries. When they analyzed the data from 256 cataract extractions, they determined that best vision was attained by those in the 40- to 74-year age range. They also found that a higher percentage of men reached the 20/20 or greater mark than women. Investigators determined that 94.3% of patients ultimately reached 20/40 corrected distance visual acuity or better and that 61.3% reached the 20/20 level, leading them to conclude that results were excellent. Factors such as ocular comorbidity, complex surgery, and surgical or short-term postoperative complications had the greatest influence on outcomes, although age and sex were also elements...

Outgoing president highlights new ASCRS educational initiatives

Thu, 09 May 2013 15:04:31 -0400

Edward Holland, MD, presents Dr. Chang with a plaque commemorating his year as
president of ASCRS at the Opening General Session.
Source: EyeWorld

It's been a great honor to serve as ASCRS president during the past year. In my speech as outgoing president at the ASCRS Opening General Session of the annual meeting last month, I reviewed some of the new educational initiatives launched by ASCRS. The speech is printed below.
David F. Chang, MD,
chief medical editor
In my address as your new president one year ago, I highlighted several core values that make our profession uniquely rewarding, including charity and our remarkable willingness to teach and help one another. Let me highlight some new ASCRS initiatives in this realm of education.
My term began with reexamination of a...

Bungee cord blowout of the capsular bag

Thu, 09 May 2013 15:04:31 -0400

Patient presented for a second opinion with hyphena and cortical opacification of the anterior lens as seen through the non-dilated pupil.

After dilation there is the suggestion of an arc-like line of delineation seen between the lens opacity and a clearer periphery in the lens on both the nasal and temporal side. The arcs look like a pair of "parenthesis" delineating the lens opacification.

Retroillumination more clearly shows the delineation of the cataract. There is an arc beyond which the lens looks almost clear.I thought that this could suggest a split in the posterior capsule.

Another retroillumination image showing what I though could be a split in the posterior capsule through which the cataract was possibly herniated.

Day one postop: IOL is placed with haptics in sulcus and...

A clear and present danger to your practice

Thu, 09 May 2013 15:04:31 -0400

A. John Kanellopoulos, MD, discusses with Josh Young, MD, the risks and benefits
of using high fluence collagen crosslinking as compared to standard collagen. Go to
ewreplay.org/
ASCRS2013/
saturday or scan the QR code above to view video.

A comic once joked that if Mike Wallace of 60 Minutes was waiting at your office's front door on Monday morning, your week wouldn't go well. This too may be said of the United States Secret Service. What follows is a cautionary tale.
Medical practices are increasingly info-tech savvy. Cutting-edge firewalls, anti-virus software, policies addressing internet usage and personal BYODs (Bring Your Own Devices), even cloud-computing for electronic health records are embraced. Widespread sharing of digital...

Inserting the Malyugin Ring

Thu, 09 May 2013 15:04:31 -0400

Figure 1. Malyugin Ring in place, providing the eight-point pupil fixation

Figure 2. Malyugin Ring insertion. The tip of the inserter is positioned close to the iris, and the distal scroll of the ring is engaged with the pupillary margin.

Figure 3. Malyugin Ring removal. The ring manipulator is pressing on both lateral scrolls in order to guide them inside the inserter tube.

Figure 4. Wound-assisted Malyugin Ring insertion through the 1.8 mm incision

Figure 5. Malyugin Ring removal through the 1.8 mm clear corneal incision
Source (all): Boris Malyugin, MD

Different techniques of modern cataract surgery require a wide and unobstructed view of the lens. When a pharmacological approach is insufficient, the surgeon usually favors the use of the...

Managing cataract surgery in post-LASIK cases

Thu, 09 May 2013 15:04:31 -0400

Lens opacity and the LASIK flap
Source: Felipe A. Soria, MD

With the amount of patients who have had refractive surgery and now need cataract surgery increasing, an effective approach is needed to achieve the best results in these cases.
"We're seeing more and more of these patients now coming in for surgery; LASIK was approved for use in 1995, so it's been almost 20 years that we've been seeing these patients," said Eric D. Donnenfeld, MD, clinical professor of ophthalmology, New York University Medical Center, New York. "Ophthalmologists should be prepared for a large number of these patients coming in for cataract surgery over the next several years. [Ophthalmologists] need to be prepared and willing and able to treat these patients to achieve the visual results that patients are accustomed to with the...

Handling a hemorrhage

Thu, 09 May 2013 15:04:31 -0400

Vikas "Vik" Chopra, MD

Associate residency program director Associate clinical chief, glaucoma service Medical director, clinical operations Doheny Eye Institute
USC Department of Ophthalmology
Los Angeles
In the typical surgeon-in-training's mind, a successful cataract surgery is to "get the lens in the bag" without having capsular rupture or vitreous loss. Any obstacle preventing attainment of this goal needs to be recognized and dealt with accordingly. The primary focus of the surgeon often is concentrated on the "critical" steps of the surgery including creation of incision and capsulorhexis, nuclear disassembly, and cortex removal. In contrast, it is not uncommon for the surgeon-in-training to pay less attention to smaller maneuvers such as paracentesis creation or eye stabilization with the fixation...

Review of "Comparisons of posterior capsular opacification and glistenings with 2 hydrophobic intraocular lenses: Five- to seven-year follow-up"

Thu, 09 May 2013 15:04:31 -0400

Pictured from left to right. Back row: David Salvay, Ian Pitha (chief resident), Aaron Lee, Manik Goel, Daniel Hammer, Sarah Jacobs, Bradley Shoss. Front row: Linda Tsai (faculty supervisor), Ling Bei, Smith-Ann Chisolm, Courtney Kraus, Kimberly Hsu, Gokul Kumar, and Arsham Sheybani (chief resident). Not pictured: Tahira Mathen, Benjamin Currie, Kisha Piggott

Introduction

Intraocular lens (IOL) placement at the time of cataract surgery is the standard of care in modern ophthalmology. Many factors must be weighed when determining which IOL to implant, including the refractive goal, lens design, and lens material. As most patients maintain their IOL in place throughout the remainder of life, how the lens will behave within the eye over time must also be taken into consideration. In this month's JCRS, Chang et al. report...

Comparison of posterior capsule opacification and glistenings with 2 hydrophobic acrylic intraocular lenses: Five- to seven-year follow-up

Thu, 09 May 2013 15:04:31 -0400

J Cataract Refract Surg (May) 2013; 39:694-698
Purpose: To compare posterior capsule opacification (PCO) and glistenings 5 to 7 years after cataract surgery with implantation of 2 hydrophobic acrylic intraocular lenses (IOLs) and evaluate the effects on corrected distance visual acuity (CDVA) and contrast sensitivity.
Setting: St. Erik Eye Hospital, Stockholm, Sweden.
Design: Randomized clinical trial.
Methods: Cataract surgery with standard phacoemulsification was performed in 1 eye of patients. The patients were randomized to an AcrySof SA60AT (1-piece IOL group) or a Sensar AR40e (3-piece IOL group), both hydrophobic acrylic IOLs with a sharp-edged design. Five to 7 years postoperatively, retroillumination images were obtained and the PCO area and severity (area affected within the capsulorhexis and severity) were evaluated using computer software. High-contrast (100%) and low-contrast (2.5%)...