Reporting live from the Hawaiian Eye Meeting, Kauai

Editors’ note: This Meeting Reporter contains original reporting by the EyeWorld News Team from the 2010 Hawaiian Eye Meeting, Kauai. Meeting Reporter is sponsored by an unrestricted grant from Advanced Medical Optics (AMO).

Hawaiian Eye 2010 got off to a good start with a Sunday program of inspiring stories from distinguished members of the ophthalmic community. Following this, Monday’s program was loaded with great information on techniques and technology in cataract surgery.

Hawaiian Eye Foundation Award

This year’s Hawaiian Eye Foundation International Award was presented to Graham Barrett, F.R.A.C.O., F.R.A.C.S., Perth, Australia and President, APACRS. In his acceptance speech, Dr. Barrett talked about his love for astronomy and the lessons he has learned from pursuing this interest that have in turn contributed to his receiving the award. These included passion for his work and interest in IOLs and cataract surgery, the important role of inspiration in life in bringing about innovation, humility in not taking for granted the unique skills required in performing successful cataract surgery, perseverance in realizing one’s aims by taking something from concept to viable product in the ophthalmic field and, appreciation for a life that allows him to pursue his passions.

Optimum results in refractive IOL surgery

At a lunch event supported by Abott Medical Optics (AMO, Santa Ana, Calif.), a distinguished panel shared their expertise in achieving optimum results in refractive IOL surgery. Speaking on the importance of pre-op evaluation to maximize the accuracy of refractive cataract surgery, William B. Trattler, M.D., Miami, said identifying and treating dry eye and blepharitis in the patient is extremely important as they can impact IOL power calculations. In addition, he said, pre-op examinations using topography and optical coherence tomography of the macula can pick up conditions not visible on direct examination. Dr. Trattler also warned that previous ocular surgery such as RK and LASIK can impact IOL power selection and potentially affect visual quality.
Also on the panel, Eric D. Donnenfeld, M.D., East Meadow, N.Y., shared some pearls for excimer laser enhancements for refractive IOLs. They included the following: Wait for refractive stability and remove any sutures (for limbal relaxing incision, two weeks; for multifocal IOLs with PRK or LASIK correction, one month; and for accomodating IOLs after YAG laser correction, four months). In patients with multifocal IOLs not centered on the pupil, perform argon laser iridoplasty prior to using the excimer laser. Custom treatments are possible with multifocal and accomodating IOLs but use caution and optimize the ocular surface. Dr. Donnenfeld said excimer laser enhancements following refractive IOL surgery is important in improving surgical outcomes and patient satisfaction. In addition, he advised all refractive IOL surgeons to learn to use the excimer laser or have some easily accessible who can treat residual refractive error when needed.

Cataract/IOL: advances in techniques and technology

In Monday’s session, Douglas A. Katsev, M.D., Santa Barbara, Calif., discussed the different premium IOLs available but said he preferred the Tecnis multifocal lens AMO) because it offers pupil-size independence, spherical aberration correction, chromatic aberration correction, material clarity, light transmission, and a posterior barrier edge design. Even though each of the lenses provide their own benefit, the total benefit the Tecnis multifocal lens provides can create a significant visual improvement for patients, Dr. Katsev said. With the Tecnis multifocal, Dr. Katsev said that it must be centered, it centers with sulcus haptics and optic capture if the rhexis is centered. It is alright to be slightly hyperopic with +.25D, it is difficult to damage the defractive surface, and kinked haptics can decenter the IOL, he said. That said, Dr. Katsev acknowledged that all three lenses are good options, that current technology is better than the past, and that it will continue to improve.
Dr. Trattler talked about the quantitative measurement of accomodation in eyes with a wavefront aberrometer. Dr. Trattler demonstrated with study data that objective accommodation can be measured accurately with a dynamic wavefront aberrometer. In phakic patients, he also showed that accommodation follows a normal age curve and is reproducible. In these patients, spherical aberration contributes to 17% of accommodation. However, in pseudophakic patients, including patients with accommodating IOLS, initial analysis found minimal objective accommodation. In addition, Dr. Trattler said that although spherical aberration plays a major role in providing an increased range of vision, however, it may also reduce the quality of near vision.
Attendees also heard an update on clinical outcomes for apodized diffractive IOLs delivered by Edward J. Holland, M.D., Cincinnati. Dr. Holland discussed the AcrySof IQ ReSTOR SN6AD3 (+4.0 D) lens and the SN6AD1 (+3.0D) lens (both Alcon, Fort Worth, Texas), which was introduced as an additional choice of add power that would move near vision distance out 6 cm to 7 cm and improve intermediate vision. Dr. Holland presented data from an Food and Drug Administration study whose objective was to confirm that the increase in the distance of near vision for the SN6AD1 (+3.0D) does not negatively impact: visual acuity at distance, intermediate or near, distance contrast sensitivity, and halo visual disturbance scores. Results at six months showed that visual performance of the +3.0D lens compared with the +4.0 D lens had a 20% increase in distance of best near visual acuity. The SN6AD1 also had a 20/25 or better visual acuity on average across a full range of near to intermediate distances. It also maintained a comparable distance visual acuity to the SN6AD3. In conclusion, Dr. Holland said that the SN6AD1 (+3.0 D) lens provides good near, intermediate and distance vision, provides a range of near vision (with best distance about 7 cm out), has a 1 to 1.5 line improvement in intermediate vision, a slight reduction in visual disturbances from 3 to 6 months, and a high rate of patient satisfaction and spectacle independence.
Managing the small pupil is one of the many challenges in cataract surgery today and Sonia Yoo, M.D., Miami, demonstrated through video presentations, how surgeons can successfully accomplish it in a variety of ways including using pharmacologic dilation, pupil stretching, Irish hooks, and pupil expansion rings.
Helen K. Wu, M.D., Boston, discussed ways in which to manage accommodating IOL complications. Myopic shift is the most common complication that can occur, she said, and it’s important to make sure initially to prevent early wound leaks by ensuring the wounds are truly water tight. Dr. Wu said she sutures all the wounds as well as the paracentesis. It is also important not to make the capsulorhexis too big because it’s easy for the lens to fall forward if the capsulorhexis is larger than the size of the optic of the lens. Also crucial to prevent complications is to have the capsulorhexis very central and Dr. Wu said she tends to rotate the lens so that both of the hinges are equally covered by the edge of the capsuhlorhexis if she doesn’t have a perfectly central capsulorhexis. At the time of surgery, she puts atropine and cyclogyl (cyclopentolate hydrochloride) in the eye and then uses cyclogyl four times a day for a week. Once there is a myopic shift, Dr. Wu said, it’s important to wait until the refraction is stable and sometimes that can take as long as three months or more. Once stabilized, the surgeon can go ahead and correct the myopia with LASIK or PRK or if they are comfortable with it, use a sulcus-based piggyback lens. When a hyperopic shift occurs, it’s important again to wait until the refraction is stable before performing enhancements, she said.
Another complication that may occur with the Crystalens (Bausch & Lomb, Rochester, N.Y.) is “Z-syndrome,” where one haptic is forward and the other haptic is backward. What happens is there is a myopic and astigmatic shift in refraction and the more “Z,” the more astigmatism, Dr. Wu said. This can occur weeks or months after surgery. The principle behind doing a YAG laser capsulotomy afterwards is to YAG the fibrotic capsule specifically behind the prolapsed haptic and then use cycloplegic agents afterwards for week or so to try to push the lens back and you may have to do it several times and sometimes you may want to go back in and actually push the lens back if it doesn’t go back into position, she said. Some surgeons who identify the Z-syndrome early on will go right in surgically and clear up whatever cortex is there, open up the bag and get viscoelastic and rotate the lens 90 degrees and that can work if done early on, Dr. Wu said.

Editors’ note: Drs. Trattler and Donnenfeld have financial interests with Abbott Medical Optics (AMO, Santa Ana, Calif.). Dr. Katsev has financial interests with AMO, Allergan (Irvine, Calif.), and Ista Pharmaceuticals (Irvine, Calif.). Dr. Holland has financial interests with Alcon (Fort Worth, Texas) and Bausch & Lomb (Rochester, N.Y.), among other companies. Dr. Yoo has financial interests with AMO, Alcon, and Carl Zeiss Meditec (Dublin, Calif.). Dr. Wu has financial interests with Inspire Pharmaceuticals (Durham, N.C.).



Comprehensive ophthalmologists received several tips and tricks in treating cataract and glaucoma patients, on the third and fourth days of the Hawaiian Eye conference.

Panel: cataract surgery complications

During a discussion where various videos were presented on cataract surgery complications, experts explained what to do in a case where a patient presents with a monocular dense white cataract. Eric D. Donnenfeld, M.D., East Meadow, N.Y., said that in a case that looks traumatic, he would perform a gonioscopy. If there is a pretty significant recession, one can be fairly certain that there’s going to be some zonular laxity at the same time and can go ahead and prepare it, he said.
Robert H. Osher, M.D., Cincinnati, said the first thing he would do is look at the lens thickness because there is now technology available that measures this. If the lens was 5.5 mm thick or more then there would be huge endocapsular pressure and this could contribute to presentation of an Argentinian flag sign, he said. Dr. Osher also noted he looks at the distance between the iris and the anterior capsule because they are usually touching (almost no gap there). If there is a gap, he said, there will be a microluxation, and the access to the vitreous should be blocked with an ophthalmic viscosurgical device and the capsule segmentally stained. Otherwise, there will be a reported loss of red reflex, leading to a blue vitreous. Dr. Osher said he would put Viscoat (Alcon, Fort Worth, Texas) around the peripheral equator and then put in Healon 5 (Abbott Medical Optics, Santa Ana, Calif.) and do the rhexis in the best manner possible.

Surgical challenges and decisions: cataract and pseudoexfoliation

Regarding the management of delayed dislocated in-the-bag IOLs, Roger F. Steinert, M.D., Orange County, Calif., said the challenge surgeons have-particularly with pseudoexfoliation cases- is despite having performed an ideal cataract surgery, the IOLs start coming in, wiggling and shifting, and the patients start having optical symptoms.. In these cases, the surgeon cannot easily perform the McCannell suture technique because the haptic is encased in the capsular bag, so the optic cannot be brought up, captured and sewn in place (there is a whole envelope around the IOL) he said. One option is to take the whole lens out, Dr. Steinert said, but there will be vitreous loss if that is done and then the surgeon will still have to put in another lens and suture it. There’s usually nothing wrong with these lenses, he said, apart from the fact that they are dislocated. To resolve this, Dr. Steinert described a Lasso suture technique using a 10-0 Prolene and an Ethicon CTC-6 needle with reduced curve. He said this is a fairly benign treatment that keeps the lens there through a small incision and the visual recovery is a lot faster for the patient. He said he tries to do this before the lenses get so unstable that vitreous is encountered.
In the case of compromised zonules, Sonia H. Yoo, M.D., Miami, recommended suturing the haptic to the iris or sclera and avoiding using eyelets. Dr. Yoo said the iris-fixated lens is most commonly a three-piece foldable lens like the Alcon MA50BM, 6.5 mm optic with a 13.0 mm diameter. The lens is folded moustache-style with a 9-0 or 10-0 Prolene suture and a long suture needle with minimal curvature like the CIF-4 or CTC. The advantages of the iris-fixated lens are that the lens can be inserted through a small incision, can be performed with a functioning bleb, and offers good visualization of suture passes. The disadvantages, however, are that it requires normal iris integrity. There is also irish chafing and chronic inflammation, an increased risk of cystoid macular edema, and a risk of iridodialysis. In describing the scleral-fixated lens, Dr. Yoo said there are variations in: the method of introducing the needle, that is, ab interno or ab externo, ways to secure the haptic and fixate the suture, number of points of PCIOL fixation, the type of PCIOL used, either a foldable acrylic lens or PMMA lens with eyelets, and method of avoiding suture erosion. The advantage to the scleral-fixated lens is that it can be used in cases where eyes have significant anterior chamber and iris disruption. The disadvantages, however, are that it is challenging to place, requires a larger incision, often requires vitrectomy, has a higher rate of lens tilt, has Prolene suture exposure and risk of vitreous hemorrhage.
Robert H. Osher M.D., Cincinnati, presented what he called the best new IOL-related complication technique in which Ehud Assia, M.D., Kfar-Saba, Israel, cleverly dealt with a malpositioned posterior chamber lens where the optic was through the middle of the pupil. Describing the procedure as a video played, Dr. Osher said the surgeon brought the optic into the anterior to try to figure out why things were not right. Dr. Assia found that the haptic had snapped off. While most surgeons would exchange the lens or reposition it, Dr. Osher said Dr. Assia decided he would create a synthetic haptic. He sewed through the optic and passed a 10-0 suture through the edge of the optic that went through fairly easily. Dr. Assia then created a lasso through the optic and passed it through the scleral wall. Then he sewed the second haptic to the iris and repositioned the lens, all of it done through a stab incision and minimally invasive surgery.

Glaucoma

Speaking from the patient’s point of view, Alan L. Robin, M.D., Baltimore, used an interview from a glaucoma patient to demonstrate many issues with adherence to glaucoma treatment, which surgeons often do not recognize. These include the following: the patient does not often know they have glaucoma, and the surgeon therefore has to make sure the patient believes that they have the disease in order to help them utilize the facilities available to them and keep them from going blind. Dr. Robin encouraged doctors not to have physician-centered discussions but rather have discussions that are related to the patient. Find out if they are having problems and ask them what issues they have, he said. In addition, he said people have trouble over weekends and when busy with activities. Try to adjust medications according to their schedule and not to what’s on the label, he said. One of the things surgeons never think about, Dr. Robin said, is how generics make a difference. If the patient is being given a generic, ask them if it is comfortable, if there is more hyperemia, and are they having trouble adhering because of that. If the drop burns they are going to find another solution or put it off and then forget. Another thing surgeons never think about, Dr. Robin said, is missing drops. He is trying to get pharmacy benefit managers to increase the number of drops allowed for a 90-day supply. There are several reasons why the drops don’t last as long as they should:if the drop misses the eye or the patient doesn’t realize more drops than required have gone into the eye because they may not be sensitive to it, and not being able to refill their prescription.
New glaucoma surgical procedures, which included external as well as internal filtering procedures, were introduced by Brian A. Francis, M.D., Los Angeles. Starting with external filtering, Dr. Francis described the Express glaucoma implant (Optonol, Kansas City, Kan.), which Dr. Francis said consists of a conjunctival dissection and scleral flap with antimetabolite placement just like trabeculectomy but instead of doing the sclerotomy with the Kelly Punch, this device is inserted with an applicator. The small tube end of the stainless steel implant can be seen in the anterior chamber and the device shunts fluid over to the subconjunctival space. Another procedure he described is the Fugo blade transciliary filtration using the Fugo plasma blade. Here again, a conjunctival flap is made but then the surgeon creates a full-thickness scleral window with this 600 micron tip. The surgeon makes a 100 micron entry through the pars plicata then enters the posterior chamber. This is a posterior chamber filter rather than an anterior chamber filter, Dr. Francis said, and fluid is drained from the posterior chamber into the subconjunctival space. In terms of internal filtering procedures, Dr. Francis described the excimer laser trabeculotomy, which is done with an excimer probe that is advanced across the anterior chamber and then placed against trabecular meshwork. Then, 5 to 10 small holes are made through trabecular meshwork. Another device, the Glaukos i-Stent (Laguna Hills, Calif.), which is like a small snorkel, is placed through a clear corneal incision. It’s advanced across the anterior chamber under a gonioscopic guidance and the sharp tip is inserted through the trabecular meshwork into schlemm’s canal, Dr. Francis said. There’s a snorkel end, which faces the anterior chamber and in effect creates an open pathway for fluid to flow from the anterior chamber into schlemm’s canal.

Editors’ note: Drs. Donnenfeld and Osher have financial interests with Abbott Medical Optics (AMO, Santa Ana, Calif.), Alcon (Fort Worth, Texas), and Bausch & Lomb (Rochester, N.Y.). Dr. Steinert has financial interests with AMO. Dr. Yoo has financial interests with AMO, Alcon, and Carl Zeiss Meditec (Dublin, Calif.). Dr. Robin has no financial interests related to his comments. Dr. Francis has financial interests with Lumenis (Santa Clara, Calif.) and NeoMedix (Tustin, Calif.).

As Hawaiian Eye 2010 wound down Thursday and Friday, attendees were not short of valuable information to improve their practices.

Ocular surface disease

Speaking in a session on infection and inflammation in ocular surface diseases, David A. Goldman, M.D., Miami, discussed tackling blepharitis. Giving a brief overview of the disease, Dr. Goldman said that blepharitis is a common eye disorder in the United States and throughout the world. In addition, although anterior blepharitis and posterior blepharitis are distinct entities, they typically coexist in the same patient. Patients with acute exacerbations need an effective treatment to address their signs and symptoms, Dr. Goldman said, and he introduced novel therapeutics for acute flare-ups. While Azasite (azythromycin, Inspire Pharmaceuticals, Durham, N.C.), a topical antibiotic has demonstrated significant improvements in meibomian gland plugging, meibomian gland secretions, and eyelid redness, Dr. Goldman said, a newer medication will soon be introduced: TobraDex ST (tobramycin and dexamethasone ophthalmic, Alcon, Fort Worth, Texas). Using supporting data, Dr. Goldman said this drug demonstrated improved suspension formulation characteristics, enhanced pharmacokinetic distribution (in rabbits and humans) and improved bactericidal characteristics compared with TobraDex. TobraDex ST therefore may provide a useful alternative to TobraDex, he said. Dr. Goldman strongly encouraged surgeons to use Azasite or TobraDex if they aren’t already, as he said it would make a big difference in their patients.
Also important in dealing with ocular surface diseases is the management of ocular herpes infections, which Francis S. Mah M.D., Pittsburgh, discussed. Dr. Mah said that if a live virus is present in these cases, surgeons should use an antiviral, which can be either topical or oral. After two weeks in a healthy patient, the virus will probably not be prevalent, he said, so the surgeon can taper off the topical or oral antiviral. If no live virus is present but an immunogenic disease is present, surgeons should use a steroid with antiviral coverage, he noted.
Nicoletta A. Fynn-Thompson, M.D., Boston, gave an update on Descemet’s stripping endothelial keratoplasty. She described the different techniques in which to perform DSEK including forceps, glide and injectors. Dr. Fynn-Thompson said the success of endothelial keratoplasty is based on atraumatic transplantation of endothelial cells and improved vision. Graft manipulation/implantation remains a challenge, she said. More post-operative studies are needed measuring cell-counts and morphology at 1 to 2 years post-op. Finally, she said, Descemet membrane endothelial keratoplasty may provide best visual post-op results, but the technique has yet to be perfected.

Refractive surgery

Kerry D. Solomon M.D., Charleston, S.C., delivered a talk on behalf of Eric D. Donnenfeld, M.D., East Meadow, N.Y., about reducing dry eye with customized femtosecond flap formation. Dr. Solomon discussed preliminary data from a study conducted by Dr. Donnenfeld, Michael C. Knorz, M.D., Mannheim, Germany, and himself, that showed an elliptical flap with a reverse side-cut, there is slightly quicker recovery of corneal sensation compared to round flaps because the inverted side-cut may make a kinder, friendlier, gentler environment for the anastomosis to occur. The elliptical flap actually pushes the hinge further out to the periphery so that you get a broader hinge and preserve more of the nerve fiber bundles, he said.
The use of a femtosecond laser system in cataract surgery was discussed by Roger F. Steinert, M.D., Irvine, Calif. He described the results of a study, which sought to evaluate the use of a new image-guided femtosecond laser system to liquefy the cataractous lens, perform a refractive capsulotomy, and create optically aligned corneal incisions for refractive cataract surgery. Dr. Steinert said results of the study found femtosecond laser applications in liquefaction was safe, effective and efficient. In addition, capsulotomy size, shape and reproducibility was statistically improved over manual techniques. Corneal incisions were reproducible and had precise dimensions and geometry. He concluded that a refractive capsulotomy (perfect shape, size, centration), liquefied lens removal with simple I/A, plus the precision of laser-created corneal incisions may enable surgeons to design and deliver an entirely new level of refractive cataract surgery.
Also discussing femtosecond laser technology was David J. Tanzer, M.D., San Diego. Dr. Tanzer described interim results of the LASIK in US Naval Aviator’s Study on improved excimer and femtosecond technology. Comparing FS60 (Abbott Medical Optics, AMO, Santa Ana, Calif) technology and the iFS with iris registration (IR) technology, Dr. Tanzer said, the study found the iFS enables a higher IR capture rate than the FS60 with no IR (a 16% increase in this case) and it’s the combination of iFs with IR that demonstrates superior results in terms of uncorrected visual acuity. It also allows for a faster overall procedure (10 seconds with the iFs and 18 seconds with the FS60). In addition, the iFS helps improve the safety profile of LASIK in terms of less suction breaks and less photo-sensitivity/inflammation (lower energy). Dr. Tanzer said the iFS and IR both contribute to better clinical results.
Y. Ralph Chu, M.D., Minneapolis, shared his early clinical experience with the I-Zip Adherent Ocular Bandage (I-Therapeutix, Waltham, Mass.). When first applied, I-Zip is blue but becomes clear upon post-op examination. Dr. Chu presented pilot study results, which concluded that the I-Ztip is comfortable for patients and effective.
Edward E. Manche, M.D., Palo Alto, Calif., presented evidence suggesting that PRK does not necessarily have an advantage over LASIK for dry eye patients. He described the results of a comparison study of dry eye findings in eyes undergoing LASIK versus PRK.
The prospective study included looked at dry eye severity, foreign body sensation, and vision fluctuations in 68 eyes of 34 myopic patients. In the patients, one eye treated with wavefront-guided LASIK and fellow eye treated with wavefront-guided PRK. Eyes were randomized by ocular dominance. Dr. Manche said that in the early post-operative period, both LASIK and PRK showed increased signs and symptoms of dry eye and dry eye severity, visual fluctuations, and corneal staining with fluorescein and lissamine green. Results showed PRK causes greater vision fluctuations than LASIK at one month post-op although both groups had persistent vision fluctuations out to six months. Dr. Manche concluded that both procedures cause a mild increase in symptoms of foreign body sensation in the early post-op period. However, all signs and symptoms return to baseline by one year post-op for both LASIK and PRK, he said.

Editors’ note: Dr. Goldman has financial interests with Alcon (Fort Worth, Texas) and Aton Pharma (Lawrenceville, N.J.). Dr. Mah has financial interests with Alcon, Allergan (Irvine, Calif.), and Inspire Pharmaceuticals (Durham, N.C.). Dr. Donnenfeld has financial interests with Abbott Medical Optics (AMO, Santa Ana, Calif.),, Alcon, and Bausch & Lomb (Rochester, N.Y.), among others. Dr. Steinert has financial interests with AMO. Dr. Chu has financial interests with AMO and Allergan. Drs. Fynn-Thompson, Tanzer, and Manche have no financial interests related to their presentations.