EyeWorld Asia-Pacific December 2012 Issue

3 December 2012 Letter from the Editor Dear Friends A s we approach the end of 2012, it is worth reflecting on some of the innovations that have become topical in the past 12 months. There is no doubt that femtosecond laser cataract surgery has become the hottest topic this calendar year and has established a foothold in the practice of cataract surgery. The debate on whether the potential benefits provided by the technology are worth the investment both by patients and surgeons will continue but there is no doubt that this approach will become more widely practiced over the next few years. Femto fragmentation of the nucleus clearly does reduce the ultrasonic energy required to emulsify the nucleus, but the major attraction remains the prospect of improved accuracy in predicted refraction provided by a more accurate and consistent capsulorhexis. This may well be difficult to demonstrate due to inherent variability in predicting refractive outcome where lens selection is often limited to the availability of IOLs in 0.5-diopter increments. What is becoming increasingly apparent are the significant differences in the capabilities of the various femtosecond laser systems that are now available. In this issue, several authors provide their own experiences with different platforms regarding consistency of rhexis creation and efficiency in nucleus fragmentation. I am sure this will continue to be an area of active discussion over the next 12 months and we will endeavor to keep our readers informed of this rapidly developing field. Despite advances in technology, complications will still occur. One of the most daunting facing cataract surgeons is the management of a dropped nucleus. This topic is covered in this issue, which contains useful techniques from surgeons on how to manage this complication. My own approach to the situation has changed over the years. I would no longer recommend converting to extracapsular extraction by enlarging the incision when faced with a capsule break and a subluxated nucleus. In my opinion, it is better to continue with emulsification as long as vitreous is not present, even at the expense of losing remaining fragments posteriorly. Similarly, I would suggest that herculean efforts to levitate the nucleus anteriorly may not be advisable and a priority for the surgeon should be to maintain an adequate scaffold for insertion of an intraocular lens. An intact rhexis will allow a sulcus placement of an implant or even better posterior capture of the optic of a foldable three-piece. This type of support is almost as satisfactory as a lens positioned in the capsular bag and does not require significant adjustment in lens power. A meticulous anterior vitrectomy is required preferably via bimanual approach and if required the patient can then be referred to a vitreoretinal surgeon for removal of any remaining nuclear material. Our vitreoretinal colleagues are extremely skilled and with modern technology are able to deal with dropped nuclear material. The final outcome is likely to be superior to what we could have achieved in the past, where we as anterior segment surgeons would go to extreme efforts to “save” a dropped nucleus. The other topic that I thought worthy of comment are the articles discussing issues relating to multifocal lenses, patient selection, and the requirement sometimes for lens exchange. Although toric lenses have become increasingly common, mulitfocal IOLs have plateaued. Although these lenses do provide a greater level of spectacle independence, this is not always the most important criterion that determines a patient’s level of satisfaction with their cataract surgery. Patients are often more concerned about quality of vision and avoiding unwanted optical disturbances such as halos than the occasional need for reading correction. Monofocal lenses actually provide superior intermediate vision to diffractive multifocals and a modest level of monovision provides added reading ability. Increasingly, the functional requirements of living in the 21st century relate more to mobile devices and computer screens rather than reading material. It is interesting to note the availability of lower-add multifocal lenses consistent with this trend. We have all encountered patients with glaucoma who after cataract surgery have a significant drop in intraocular pressure. The question that always arises is whether cataract surgery can be considered an effective treatment for glaucoma. A recent analysis of the ocular hypertension treatment study (OHTS) addresses this issue in an article in the journal but cautions that a significant reduction of 20% or more only occurred in about 40% of OHTS participants. After cataract surgery, the data therefore suggests that a reduction in IOP should be considered a benefit of cataract surgery but there is insufficient evidence as yet to recommend this as a reliable treatment for glaucoma in patients without significant cataract. I hope you will enjoy the articles I have highlighted as well as the many others which contain information of interest to cataract and refractive surgeons in our region. I would like to take this opportunity to wish everyone a happy festive season and good health, happiness, and prosperity for the forthcoming year. Warmest regards Graham Barrett, MD President, APACRS, Chief Medical Editor, EyeWorld Asia-Pacific EYEWORLD ASIA-PACIFIC EDITORIAL BOARD C HIEF MEDICAL EDITOR Graham BARRETT, Australia MEMBERS Abhay VASAVADA, India ANG Chong Lye, Singapore CHAN Wing Kwong, Singapore CHEE Soon Phaik, Singapore Choun-Ki JOO, Korea Hiroko BISSEN-MIYAJIMA, Japan ASIA-PACIFIC CHINA EDITION Editors-in-Chief ZHAO Jialiang ZHAO Kan Xing Deputy Editor HE Shouzhi Assistant Editor Zhou Qi ASIA-PACIFIC INDIA EDITION Regional Managing Editor S. NATARAJAN ASIA-PACIFIC KOREA EDITION Regional Editor-in-Chief Hungwon TCHAH Regional Managing Editor Chul Young CHOI Hung-won TCHAH, Korea John CHANG, Hong Kong Johan HATAURUK, Indonesia Kimiya SHIMIZU, Japan Pannet PANGPUTHIPONG, Thailand Prin ROJANAPONGPUN, Thailand Ronald YEOH, Singapore S. NATARAJAN, India YAO Ke, China YC LEE, Malaysia