EyeWorld Asia-Pacific June 2012 Issue

June 2012 8 EWAP NEWS & OPINION MD, PhD, who represented ASCRS and co-chaired the symposium. “That time is long gone.” Today, Dr. Stulting said that he learns more exciting new things by attending international meetings outside of the U.S. The sophisticated surgeon, he said, can now be found all over the world. Before Where are we today with cataract surgery? asked Dr. Yeoh (APACRS). Cataract surgery today, he said, promises patients the potential for a full range of vision and, in the best cases, spectacle freedom. Assuming that a cataract surgeon chooses the appropriate lens and performs consummate surgery, the remaining factor for delivering on this promise is patient selection. On the most basic level, he said, patient selection depends on your own aim for your patients. Dr. Yeoh’s particular aim is providing patients spectacle independence. This entails a thorough examination of the patient before surgery including refraction, ocular health, type of cataract, and assessment of the fundus. Appropriate patient selection and counseling, he said, go a long, long way towards achieving the best outcomes and making patients happy. Successfully predicting outcomes before surgery also goes a long way towards making patients happy, said Dr. Stulting. He said that doing so requires setting realistic expectations and maximizing uncorrected visual acuity (UCVA). UCVA, he said, is the ultimate benchmark for successful surgery, at least from the patient’s perspective. Dr. Stulting discussed what he called “potential game changers” for predicting outcomes. These include OCT-based calculations, intraoperative aberrometry, femtosecond laser capsulotomy, and developments represented by the Light Adjustable Lens (LAL, Calhoun Vision, Pasadena, Calif., USA). Clive Peckar, MD (ESCRS), rounded out the discussion of things to consider before surgery with his personal approach to IOL selection. Dr. Peckar said that he does not use hydrophobic or silicone IOLs, instead preferring hydrophilic lenses. A hybrid lens material is also in development, combining the advantages of the two materials while minimizing their disadvantages by having them cancel each other out. Selecting the most appropriate IOL also requires assessing your patient. Multifocal IOLs, which provide a wider range of vision but with the by now well-known trade- offs in terms of visual quality, require patient profiling, which is not required with monofocal IOLs. Dr. Peckar observed that, while most surgeons including himself will have seen patients requesting IOL exchange after multifocal IOL implantation, he has never had to perform an IOL exchange in a patient implanted with a monofocal IOL. During In describing his personal choice of surgical technique, Prof. Barrett considered the safety, efficacy and efficiency of three approaches to surgery: divide and conquer; horizontal chop techniques typified by stop and chop; and vertical chop techniques, particularly the phaco- axe. Divide and conquer, he said, is a simple and predictable technique that is well-suited for teaching phaco; it is safe but requires a “fair amount of energy” and so is “not very efficient”. Horizontal chop techniques, in comparison, are less safe but are at least as effective and certainly more efficient. But Prof. Barrett’s choice is the vertical chop phaco-axe technique, which is safer than either divide and conquer or horizontal chop by causing less stress to either the zonules or the capsule. Conducting a study looking at energy modulation, energy control, and surgical technique in terms of impact on energy requirement during phaco, Prof. Barrett found that surgical technique had the greatest impact; as such, he said it is worth considering the phaco-axe as a “sophisticated technique for sophisticated surgeons”. As incisions get smaller, fluidics—always an important part of cataract surgery to begin with, necessary for maintaining space, creating currents and “keeping things cool” in the eye during phaco surgery—need to be more tightly controlled, said Farrell C. “Toby” Tyson, MD (ASCRS). The good news is that modern phaco machines provide the technology necessary for surgeons today to keep the kind of control they need on fluidics. Aside from delivering the best outcomes, avoiding complications defines success during cataract surgery. Peter Barry, MD , ESCRS president and the third co-chair of the CSCRS, recommended using intracameral cefuroxime prophylactically, as supported by the results of the famous ESCRS study on endophthalmitis. In addition, he said surgeons should aim for watertight incisions, precision biometry, and using a technique that avoids undue stress on the posterior capsule. After Despite advances in modern cataract surgical technology and techniques, complications can still occur. The final aspect of “sophisticated surgery” examined by the CSCRS involved the management of these complications. Prof. Yao (APACRS), looked at the various situations in which an IOL exchange may be necessary, including breakage of the IOL loop or optic segment during implantation, IOL opacification, IOL dislocation, and insertion of the wrong lens power, and, when intolerable for the patient, visual phenomena such as glare. Finally, in a two-part discussion of the correction of any residual refractive error, Beatrice Cochener, MD (ESCRS), and APACRS - from page 7