APACRS 2021 Daily News (Saturday, 31 July 2021)

Asia-Pacific Association of Cataract & Refractive Surgeons Saturday, 31 July 2021 EWAP Daily News - 3 MIGS, then, Dr. Makornwattana said, help delay traditional surgery by providing add-on IOP lowering with a greater degree of safety, though they are limited by being only able to provide mild to moderate IOP lowering and requiring more skills with a not insignificant learning curve for sur- geons. Dr. Makornwattana cited ocular conditions such as con- junctival hyperemia, previous ocular surgery, and conjunc- tival scars as reasons to avoid MIGS, but ultimately said that “there is no ‘NO’ in glaucoma treatment,” meaning treatment should be tailored to each patient, with decisions made together with them and according to their particular needs to help them “keep their vision forever.” Taking the opposite tack, Graham Lee, MD, MBBS, FRANZCO, Australia, detailed when not to do trabeculec- tomy. He noted that the ideal patient for trabeculectomy has healthy tissue in “virgin eyes”; primary open-angle glaucoma (POAG), which doesn’t usually have a lot of in- flammation; are receiving primary glaucoma treatment; and have compliant personalities. Trabeculectomy then is not the optimal choice for patients with scarred conjunctiva or thin sclera, secondary forms of glaucoma such as uveitic, neovascular, or aphakic glaucoma, and who have been on long-term multiple topical medications, particularly if the conjunctiva has been destroyed by exposure to the preser- vative benzalkonium chloride (BAK). Provided with this context, Leonard Yip, MD, Singapore, asked “when is it time to go back to doing a trabeculecto- my?” Focusing on factors related to the patient’s eye, Dr. Yip said that trabeculectomy becomes the option when large IOP pressure reductions most MIGS currently cannot deliv- er are required; when angle or anterior chamber abnormali- ties make MIGS unsuitable; when use is off-label for MIGS; and following MIGS failure. “Fortunately, severe MIGS failures requiring repeat surgery are not common,” he said. “However, trabeculectomy or reviving the trabeculectomy can be sight saving in such cases.” MasterClass: Managing the Posterior Segment in Cataract Surgery The MasterClass “Managing the Posterior Segment in Cat- aract Surgery” presented a wide variety of lecturers who presented management of complications related to cata- ract surgery along with case presentations. Caroline Chee, MD, Singapore, presented on cataract surgery after retinal surgery in which it is common for both eyes to be highly myopic. However, Dr. Chee says, “it is preferable not to target more than 3 D of myopia after cataract surgery.” The timing of surgery is important and visual acuity as well as visual requirements of the patient must be considered. Daniel Ting, MD, PhD, Singapore, discussed managing coexisting diseases such as diabetes with cataract surgery. Preoperatively, one must look at the patient systematically and consider the patient’s control of risk factors such as blood pressure and cholesterol. If patients have systemic conditions (previous strokes or heart disease) that require blood thinners, the surgeon may need to consult about stopping these medications preoperatively. Manish Nagpal, MS, DO, FRCS, India, spoke about man- aging posterior capsular rent: one should notice posterior capsular rent “as soon as possible so s/he can control the damage.” He also spoke on nucleus drop, stating that vit- reous surgeons should clean nucleus drops right away and avoid using jet-like irrigation to elevate the lens, which can lead to retinal breaks. Other complications such as vitreomacular interface dis- eases are being increasingly detected in patients with cataracts. “Although the best surgery approach for these patients is yet to be determined, cataract surgery alone may provide sufficient improvement in vision,” says Danny Cheung, MD, Singapore. In age-related macular degener- ation patients, Anna Tan Cheng Sing, MBBS, BSc, Mmed, FAMS, FRCSEd, Singapore, says patients can still benefit from cataract surgery as well without significant visual acu- ity changes. By under-promising outcomes to the patient and over-delivering, both surgeons and patients will benefit greatly.