eyeworldap.apacrs.org The Asia-Pacific Association of Cataract and Refractive Surgeons ASIA-PACIFIC Vol. 18 No. 4 December 2022 Licensed Publication www.eyeworldap.apacrs.org
References: 1. Rangarajan R, Kraybill B, Ogundele A, Ketelson H. Effects of a hyaluronic acid/hydroxypropyl guar artificial tear solution on protection, recovery, and lubricity in models of corneal epithelium. J Ocul Pharmacol Ther. 2015;31(8):491-497. 2. Davitt WF, Bloomenstein M, Christensen M, Martin AE. Efficacy in patients with dry eye after treatment with a new lubricant eye drop formulation. J Ocul Pharmacol Ther.2010;26(4):347-353. 3. Rolando M, Autori S, Badino F, Barabino S. Protecting the ocular surface and improving the quality of life of dry eye patients: a study of the efficacy of an HP-guar containing ocular lubricant in a population of dry eye patients. J Ocul Pharmacol Ther. 2009;25(3):271-278. 4. Ogundele A, Kao W, Carlson E. Impact of Hyaluronic Acid Containing Artificial Tear Products on Re-epithelialization in an In Vivo Corneal Wound Model. Poster presented at: 8th International Conference on the Tear Film & Ocular Surface; September 7-10, 2016; Montpellier, France. See instructions for use, precautions, warnings and contraindications © 2021 Alcon Inc. ASIA-SYH-2100002
EWAP DECEMBER 2022 3 Vaishali Vasavada, MD Guest Editor EDITORIAL EyeWorld Asia-Pacific • December 2022 • Vol. 18 No. 4 Champions are Brilliant at Basics ----- John Wooden I feel humbled and delighted as I write this editorial for the penultimate issue of 2022. And what better theme than to revisit the basics of cataract and refractive surgery, when one is embarking upon another new year, one filled with hope and promise of better things to come. This issue reminds us that no matter how many sophisticated diagnostics and therapeutics we add to our practice, we can only utilize them best when we know our fundamentals. Unless we understand the physics, mechanics, and optics of every device and technique, it is unlikely that we will truly achieve excellence in our outcomes despite the most modern technology. Cataract surgery has come a long way, and modern phacoemulsification systems are extremely efficient, helping surgeons to enhance their surgical performance. However, both the surgeon and technology will be tested in challenging environments such as dense cataracts, small pupils, floppy irides, and extremes of biometry. Keep in mind that the input and output from the eye need to be balanced, and that keeping a less turbid intraocular environment keeps the uveal tissue flutter at bay and helps maintain a lower intraocular pressure. It is here that technology that allows us to operate using lower parameters, use ultrasound/laser energy more efficiently, and protect from surge will come in handy. A smart surgeon is one who is able to then customize the machine parameters for each scenario, and use the advanced features of technology in trying conditions. Another good example of basics first is the intravitreal injections. With the safety and efficacy of anti-VEGF and steroids, they are now being used extensively, and most often multiple times in each eye. However, what we must carefully watch out for in these patients is short- and long-term intraocular pressure rise. I have personally seen instances of patients reporting no perception of light and even vitreous herniation following intravitreal injections. A simple practice of checking light perception as well as globe pressure at the end of injection would go a long way in protecting the retina and optic nerves in these eyes which often have ocular or systemic comorbidities. Corneal refractive surgery and presbyopia correcting IOL technology is evolving at a fast pace, and we now have many more options that allow us to confidently deliver both quantity and quality of vision. Yet missing out subtle ocular surface problems in refractive cataract surgery often lands surgeons in trouble with nagging, unhappy patients and a bad name for the IOL technology. Using newer imaging for corneal irregularities, wavefront analytics, and ocular surface disease, one can now not only diagnose but even predict the visual performance to a large extent. And yet, one must remember that every new technology needs to be tested and validated in a particular patient demography. To be used widely, the technology must be scientifically robust and also have ease of operation apart from being pocket friendly! All in all, every feature of this issue, be it on corneal astigmatism, the ever-elusive angle alpha (and its many interpretations!!), the good old trabeculectomy and the surprisingly insightful data from the clinical registry at a large healthcare setup is worth your time. I also think it is time we all start focusing our research and innovation on the amount of biowaste we generate and sooner than later re-evaluate some of the practices that could be more wasteful than useful. Any small change that can have a positive environmental impact is the dire need of the day, and of the times to come. I wish you all a Very Happy Year End and a Happier, More Fruitful Year to Come. Let us all pledge to keep thinking about every small aspect that we often perform mechanically in our daily lives. Let us continue striving for something better, something newer, something that carries forward the legacy left to us by our predecessors.
4 EWAP DECEMBER 2022 CONTENTS CATARACT 07 A look at phaco fluidics by Ellen Stodola 08 Factoring astigmatism into cataract surgery decisions by Ellen Stodola 10 A primer on interpreting OCT for cataract surgery by Liz Hillman 13 Adopting the Light Adjustable Lens: Implementation and personal experience by Ellen Stodola 26 The role of corneal imaging for IOL planning by Liz Hillman 03 Editorial REFRACTIVE 18 Clearing up angle kappa by Liz Hillman 21 The impact of corneal aberrations on refractive surgery by Ellen Stodolaby GLAUCOMA 30 IOP elevation related to intravitreal injections by Ellen Stodola 33 The case for trabs: ‘Trabeculectomy is not dead’ by Liz Hillman CORNEA 23 A breakdown of evaporative and aqueous tear deficient dry eye by Liz Hillman NEWS & OPINION 35 Sustaining safe, quality, cost- effective care: A clinical registry study at the Aravind Eye Care System assessing traditional and Western operating room practices by Aakriti G. Shukla, MD, and David F. Chang, MD 38 Review of ‘Real-world incidence of monofocal toric intraocular lens repositioning: Analysis of the American Academy of Ophthalmology IRIS Registry’ by Lisa Koenig, MD, Charles Cole, MD, Brigette Cole, MD, Grace Sun, MD, and the Weill Cornell Medicine ophthalmology residents 40 Review of ‘Effect of time since primary laser-assisted in situ keratomileusis on flap relift success and epithelial ingrowth risk’ by Anthony Mai, MD, Mike Murri, MD, and Jeff Pettey, MD, THE FUNDAMENTALS OF CATARACT & REFRACTIVE SURGERY
NEXUS CoNNECtiNg EvEryoNE & EvErythiNg Preliminary Program Overview 8 JUNE 2023 (THU) 9 JUNE 2023 (FRI) 10 JUNE 2023 (SAT) 07:30 – 8:45hrs (S5) THE CATARACT METAVERSE 1 Everything Everywhere All at Once 07:15– 08:15hrs (S11) IIIC LECTURES The Perfect Save! 09:00 – 10:30hrs MASTERCLASSES (MC1) Mastering Toric IOLs (MC2) Mastering Pterygium Surgery (MC3) Mastering Paediatric Cataract Surgery 09:00 – 10:30hrs OPENING CEREMONY & APACRS LIM LECTURE 08:15 – 11:15hrs (S12) SURGICAL VIDEO SYMPOSIA (S1) ANGLE CLOSURE SURGERY: NEW INSIGHTS TEA BREAK 11:00 – 12:30hrs MASTERCLASSES (MC4) Mastering Biometry (MC5) Mastering Refractive Surgery Complications (MC6) What They Don’t Teach You in Residency 11:00 – 12:30hrs COMBINED SYMPOSIUM OF CATARACT & REFRACTIVE SOCIETIES (CSCRS) (S6) TRENDING TECHNOLOGIES Highway to the Future 11:15– 12:45hrs (S13) GLITCH IN THE MATRIX Challenging Cataract Cases (S14) FASTER THAN THE SPEED OF LIGHT Changing Patterns in Refractive Surgery NURSING & ALLIED HEALTH (S7) HOLISTIC EYE CARE: A MULTIDISCIPLINARY APPROACH (PART 1) (S2) UPDATES ON INFECTIOUS KERATITIS FREE PAPERS NURSING & ALLIED HEALTH (S15) HOLISTIC EYE CARE: A MULTIDISCIPLINARY APPROACH (PART 2) FREE PAPERS INDUSTRY LUNCH SYMPOSIA 14:00 – 15:30hrs MASTERCLASSES (MC7) Mastering Phaco Alternatives (MC8) Mastering Corneal Endothelial Transplantation (MC9) Mastering Phakic IOLs 14:00 – 15:30hrs (S8) THE NETWORK IS DOWN Managing Cataract Complications 14:00 – 15:30hrs (S16) THE CATARACT METAVERSE 2 Everything Everywhere All at Once (S9) THE NEW BLACK IN PRESBYOPIA CORRECTION (S17) ANTERIOR SEGMENT INNOVATIONS (S3) MYOPIA-ASSOCIATED OPTIC NEUROPATHY OR GLAUCOMA FREE PAPERS FREE PAPERS TEA BREAK 16:00 – 17:30hrs MASTERCLASSES (MC10) Mastering IOL Fixation (MC11) Mastering Vitrectomy for Anterior Segment Surgeons (MC12) Mastering MIGS 16:00 – 17:30hrs (S10) FILM FESTIVAL SYMPOSIUM & AWARDS CEREMONY 16:00 – 17:30hrs (S18) TOP GUN Top Cataract Surgery Tips (S4) GLOBAL TRENDS IN THE FIELD OF CORNEA 17:30 – 19:00hrs WELCOME RECEPTION MORNING AFTERNOON Visit www.apacrs2023.org for more information
EYEWORLD ASIA-PACIFIC APACRS Publisher: EyeWorld Asia-Pacific Edition (ISSN 1793-1835) is published quarterly by the Asia-Pacific Association of Cataract & Refractive Surgeons (APACRS), c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (65) 6322-7469, fax (65) 6327-8630, email ewap@apacrs.org. Printed in Singapore. Editorial Offices: EyeWorldAsia-Pacific Edition: Asia-Pacific Association of Cataract &Refractive Surgeons (APACRS), c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (65) 6322-7469, fax (65) 6327-8630, email ewap@apacrs.org. AdvertisingOffice: EyeWorldAsia-PacificEdition:Asia-PacificAssociationofCataract&RefractiveSurgeons (APACRS), c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (1-703) 975-7766, email don@apacrs.org. Copyright 2021, Asia-Pacific Association of Cataract & Refractive Surgeons (APACRS), c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (65) 6322-7469, fax (65) 6327-8630, email ewap@apacrs.org. Licensed through the American Society of Cataract & Refractive Surgery (ASCRS), 4000 Legato Road, Suite 700, Fairfax, VA 22033-4003, USA. All rights reserved. No part of this publication may be reproduced without written permission from the publisher. Letters to the editor and other unsolicited material are assumed intended for publication and are subject to editorial review and acceptance. The ideas and opinions expressed in EyeWorld Asia-Pacific do not necessarily reflect those of the editors, publishers or its advertisers. Subscriptions: Requests should be addressed to the APACRS publisher, c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (65) 6322-7469, fax (65) 6327-8630, email ewap@apacrs.org. Back copies: Subject to availability. Contact the APACRS publisher, c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (65) 6322-7469, fax (65) 6327-8630, email ewap@apacrs.org. Requests to reprint, use or republish: Requests to reprint or use material published herein should be made in writing only to the APACRS publisher, c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (65) 6322-7469, fax (65) 6327-8630, email ewap@ apacrs.org. Change of address: Notice should be sent to the APACRS publisher, c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, six weeks in advance of effective date. Include old and new addresses and label from a recent issue. The APACRS publisher cannot accept responsibility for undelivered copies. KDN number: PPS1766/07/2013(022955) MCI (P) 039/02/2022 CHINESE EDITION Regional Managing Editor Yao Ke, MD Deputy Regional Editor He Shouzhi, MD Zhao Jialiang, MD Assistant Editors Zhouqi, MD Shentu Xingchao, MD INDIA EDITION Regional Managing Editor S. Natarajan, MD Deputy Regional Editor Abhay Vasavada, MD KOREAN EDITION Regional Managing Editor Hungwon Tchah, MD Deputy Regional Editor Chul Young Choi, MD EDITORIAL BOARD Chief Medical Editor Graham Barrett, MD Chief Publisher Ronald Yeoh, MD Executive Director Kathy Chen kathy.chen@apacrs.org Publishing Consultant Donald R Long don@apacrs.org PUBLISHING TEAM Senior Staff Writer Chiles Aedam R. Samaniego chiles.samaniego@apacrs.org Production Team Javian Teh Gretel Tan Christine Shimmon Aileen Bian ewap@apacrs.org Chan Wing Kwong, MD, Singapore Ronald Yeoh, MD, Singapore John Chang, MD, Hong Kong SAR Pannet Pangputhipong, MD, Thailand YC Lee, MD, Malaysia Hiroko Bissen-Miyajima, MD, Japan Kimiya Shimizu, MD, Japan Sri Ganesh, MD, India Chee Soon Phaik, MD, Singapore Johan Hutauruk, MD, Indonesia EDITORIAL MEMBERS
CATARACT EWAP DECEMBER 2022 7 Dr. Lubeck uses Active Fluidics with the Centurion Vision System. Source: David Lubeck, MD Contact information Lubeck: dmaclubes@earthlink.net A look at phaco fluidics by Ellen Stodola Editorial Co-Director This article originally appeared in the September 2022 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Understanding the basic concept of phaco fluidics is important for successful cataract surgery, particularly when differentiating among the systems available and how they can help surgeons and patients. David Lubeck, MD, broke it down in a discussion with EyeWorld. In beginning to discuss this topic, Dr. Lubeck said you need to go back to the basic premise of phaco fluidics. Everything done in the system, every parameter in passive/ gravity fluidics—including the bottle height, incision size, the phaco sleeve size, the second incision size, the height of the bed, the patient eye level, flow rate, vacuum setting, and the efficiency of the pump—is related to how stable the eye is going to be during cataract surgery. “You can’t look at only one part of the system to determine the fluidics,” he said. “You have to look at every piece of it to understand it, then if you want to maximize your intraocular stability, you have to be able to manipulate the different pieces of the system to your advantage.” The first component in fluidics stability is the infusion pressure, the pressure of the fluid going into the eye and how well you can maintain that at a constant level. When you have a gravity infusion system, the higher you raise the bottle, the higher the pressure you can create, but the more the pressure will drop when you have an occlusion break or when you have inefficiencies in the system beyond the fluid inflow, Dr. Lubeck said. “With a gravity fluidics system, you can raise the infusion pressure by raising the bottle, but in doing so you also are creating a higher gradient for surge and loss of intraocular stability,” he explained. Dr. Lubeck uses Active Fluidics with the Centurion Vision System (Alcon). With this system, he said the infusion of balanced salt solution is pressurized to a specific level. There is also a sensor and valve system in the machine that is constantly monitoring the pressure in the eye or the pressure in the tubing connected to the eye, and the valve is opening and closing in milliseconds to keep the intraocular environment as stable as possible, Dr. Lubeck said. He thinks this option provides more control and stability of the intraocular pressure than using a gravity infusion system. Dr. Lubeck noted that other companies also have advanced phaco systems. Other options in this class of advanced fluidics systems include Bausch + Lomb’s StableChamber using the Stellaris Vision Enhancement System and Johnson & Johnson Vision’s hybrid fluidics using the Veritas Vision System, as well as the QUATERA 700 from Carl Zeiss Meditec. You want the most stable possible intraocular environment for all procedures, Dr. Lubeck said, so once you use a machine with advanced fluidics, you continued on page 17
CATARACT 8 EWAP DECEMBER 2022 Contact information McCabe: cmccabe13@hotmail.com Schallhorn: scschallhorn@yahoo.com In the spirit of the “Back to basics” theme of this issue, Steven Schallhorn, MD, and Cathleen McCabe, MD, discussed the important topic of identifying astigmatism prior to cataract surgery: how to determine the level of astigmatism, when to address it, and how even low levels may have an impact. Dr. Schallhorn said the most important thing is taking the time to measure the corneal astigmatism. “That’s the critical component,” he said, adding the clinicians might get tripped up if they don’t see much astigmatism in patients’ glasses and choose to disregard it. “If a patient has very little astigmatism in their prescription, Factoring astigmatism into cataract surgery decisions by Ellen Stodola Editorial Co-Director eyecare providers often don’t think about measuring corneal astigmatism, so that is the most important basic element,” he said. “The act of measuring is the most important first step.” A patient can have a diopter or less of manifest astigmatism and have much more than that in corneal astigmatism. The corneal astigmatism primarily determines the post-cataract procedure manifest astigmatism. As far as measuring goes, Dr. Schallhorn said there is great technology for this. “We can now measure the total power of the cornea, combining both the anterior and posterior cornea components,” he said. “This is especially important if the corneal shape has been altered, such as patients who have undergone laser vision correction.” Dr. McCabe said that this is an important topic, particularly because many people find it intimidating. She stressed that one of the most important things is to ensure the health of the ocular surface when performing and analyzing measurements. “I think the simplest thing is to carefully examine the patient. During the cataract evaluation, some practices will do biometry, topography, Ks, and axial length on the same day,” she said. “If you do that, make sure you do it at the beginning before anything has touched the eye. What we decided to do is separate those visits, so we can make The relationship between manifest astigmatism and uncorrected distant visual acuity at 3 months postop for 13,267 dominant eyes implanted with a multifocal IOL. This shows even low levels of astigmatism affect unaided vision. Source: Steven Schallhorn, MD 83.7% 77.4% 68.5% 50.8% 36.1% 18.6% 8.9% 4.3% 9.1% 54.4% 47.1% 32.9% 18.7% 10.4% 4.2% 0.5% 0.0% 1.8% 0% 25% 50% 75% 100% 0 0.25 0.5 0.75 1 1.25 1.5 1.75 >=2.0 % of eyes Residual manifest astigmatism 20/20UCDVA 20/16 UCDVA This article originally appeared in the September 2022 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp.
CATARACT EWAP DECEMBER 2022 9 sure that every patient is at least using lubricating drops prior to biometry and has a greater likelihood of having an ocular surface that is pristine and not dry.” For accurate measurements, Dr. McCabe suggested having a way to reliably and accurately obtain the corneal curvature/ Ks, noting there are several technologies for this. She also said it’s important to have an idea about the shape of the astigmatism, if it’s irregular, indicating a complex cornea, or regular astigmatism. “You don’t have to get super sophisticated about that, but you do need a picture of the central curvature of the cornea that tells you whether the astigmatism is regular or not,” she said. This can be determined with a topographer or even manual keratometry, looking for clear, sharp, and orthogonal mires. Having this basic information, Dr. McCabe said, helps set surgeons up for successful astigmatism treatment. Then you have to decide how to treat. There are several reasons that many physicians lean toward putting in a toric lens, if it’s indicated, she said. First, there is long-term stability and predictability of toric IOLs. “We don’t have to factor in healing of the arcuate incision, healing that’s individual to the patient,” Dr. McCabe said. Second, this option doesn’t impact ocular surface health, while arcuate incisions and cutting through the corneal nerves can worsen dry eye in the postoperative period. For these reasons, Dr. McCabe said she uses a toric lens when indicated, however, she noted that, in the U.S., low power torics are not available. “There are lower levels of astigmatism that I still think are important to treat, especially if we’re putting in a diffractive optic, and in those cases where it’s a lower level of astigmatism, I’ll do arcuate incisions,” she said. “I think allowing patients to have the best quality of vision at distance is what they find to be most important,” she said. “We can provide an increased independence with excellent distance vision for most patients, and that fundamentally depends on accurate and universally applied astigmatism correction.” The effect of residual astigmatism was the subject of an extensive study1 in which Dr. Schallhorn participated, looking at different amounts of astigmatism to determine what effect they have. “Above a relatively low level, you should consider addressing it to achieve the best unaided postoperative vision and maximize patient satisfaction,” he said. Dr. Schallhorn’s study found that even low levels of postoperative astigmatism can impact unaided vision and patient satisfaction after surgery. This includes 1 D or 0.75 D, but even down to 0.25–0.5 D. He called this conclusion a “wakeup call” for physicians to pay closer attention to corneal astigmatism and how to best address it. He also said that industry will play a big role in helping to develop better ways of correcting astigmatism, especially low levels. “Moderate to high levels of corneal astigmatism can be effectively addressed with toric IOLs, but if we want to raise the bar and improve outcomes, we need to refine methods to treat lower levels, both on the clinical side and on the industry side.” For example, Dr. Schallhorn said this could mean further developing and obtaining regulatory A s a preoperative evaluation of astigmatism, it is important to quantitatively evaluate the anterior and posterior corneal astigmatism and the condition of the cornea. In my opinion, the degree of astigmatism to be corrected for good postoperative visual acuity is 1.0 D or more for with-the-rule and against-the-rule astigmatism, and 0.75 D or more for oblique astigmatism. In addition, when using a multifocal IOL, residual astigmatism significantly affects postoperative visual acuity, so even preoperative corneal astigmatism of less than 0.75 D is carefully corrected. I also agree with Dr. Schallhorn that a slight hyperopic setting should be used to achieve good postoperative visual acuity. I developed the world’s first toric IOL in 19921, but it didn’t solve the problem of an average misalignment of 4 degrees, or about 12% undercorrection. Therefore, it is also important to work with this corrective effect in mind when using toric IOLs. Reference 1. Shimizu K, et al. Toric intraocular lenses: Correcting astigmatism while controlling axis shift. Cataract Refract Surg 1994; 20(5): 523-526. Editors’ note: Dr. Shimizu is a consultant for STAAR Surgical AG and KOWA. Kimiya Shimizu, MD Professor, Sanno Hospital 8-10-16 Akasaka, Minato-ku, Tokyo, Japan kimiyas@iuhw.ac.jp ASIA-PACIFIC PERSPECTIVES continued on page 12
CATARACT 10 EWAP DECEMBER 2022 Contact information Charles: scharles@att.net Zhu: dagny.zhu@gmail.com C ontinuing with the “Back to basics” theme of this issue, EyeWorld spoke to Dagny Zhu, MD, and Steve Charles, MD, for a primer on interpreting OCT of the macula and optic nerve in preparation for cataract surgery. The cataract surgeon is primarily using OCT to detect retinal or glaucoma pathology that could affect whether a patient is a candidate for a premium, presbyopia-correcting IOL. If pathology is detected for the first time that potentially requires treatment, they refer the patient to a retina specialist. “If you diagnose an issue that you think will be limiting vision, you refer to a retina specialist for their intervention. I think the cataract surgeon should be good at some of those basic diagnoses,” Dr. Zhu said. “With glaucoma, it can be tricky whether the patient truly has glaucoma or not, so I might refer to a glaucoma specialist for clearance on whether they are a glaucoma suspect rather than an actual glaucoma patient.” Dr. Zhu said she uses the Optovue Avanti OCT device. This device does the basics that she needs—OCT of the macula and optic nerve head— in addition to anterior segment OCT, which can be helpful when A primer on interpreting OCT for cataract surgery by Liz Hillman EyeWorld Editorial Co-Director there’s a need to look at the angle and/or cornea. Epithelial thickness mapping is another useful feature that can help diagnose subclinical keratoconus or epithelial basement membrane dystrophy, both of which can affect final visual outcomes. Dr. Zhu said she does OCT on all cataract and refractive lens exchange patients. She thinks that because it’s an out-of-pocket expense, not all cataract surgeons do it. “I treat everyone as a potential premium IOL candidate when they walk through the door, so I get an OCT on everyone even before I see the patient to confirm that a multifocal or trifocal IOL is an option for them. If an abnormality is detected, depending on the extent of posterior pathology, we may limit the options to an extended depth of focus IOL or monofocal IOL instead. Even if we end up using a monofocal IOL, the OCT gives you an idea of the visual potential of the patient. You can counsel them on what their vision might be after cataract surgery because if you find a thick epiretinal membrane or signs of geographic atrophy, their vision might not be as good as you would expect after cataract surgery, and they might be disappointed. An OCT is also helpful in counseling the patient on whether they may need an additional intervention before or after surgery, for example, anti-VEGF injections prior to cataract surgery in an eye with diabetic macular edema or wet age-related macular degeneration to reduce the chances of postop inflammation,” she said. Dr. Charles emphasized that he thinks OCT should be obtained for all cataract surgery candidates as well and said he also recommends OCT at every office after cataract surgery. OCT primer 1. Familiarize yourself with what a normal OCT of the macula looks like. “Refresh yourself on the different layers of the retina,” Dr. Zhu said. “Oftentimes it’s easy to miss pathology in the inner and outer layers of the retina. If it’s mild atrophy, you might not pick up on the missing retinal layers if you aren’t familiar with what a normal OCT looks like. Sometimes you’ll see a subtle localized RPE defect, and that’s a sign of long-standing atrophy.” 2. Consider but don’t necessarily rely on retinal mapping features. “If you’re not good at inter-preting each layer, you This article originally appeared in the September 2022 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp.
CATARACT EWAP DECEMBER 2022 11 can use the retinal mapping features on OCT. It will pull up a picture for you and flag areas of atrophy as red. … The healthy areas are green,” Dr. Zhu said, adding that she prefers to scroll through every slice of the OCT herself to better localize defects. Dr. Charles said he does not advise using thickness maps or pseudo-color. “Review all black and white B-scan slices,” he said. “Do not import a technician-selected single image into EMR; use native imaging software.” 3. Look at more than one area. Dr. Zhu has her technicians print out the sheet with multiple slices for her review, so she doesn’t miss relevant pathology. “I think it’s important to capture as many slices as possible. Sometimes the surgeon doesn’t have time to sit there and scroll, so you’re relying on the technician to print out the best image for you, and some will print out that one view with the one slice of the fovea and you miss out on the other pathologies. Get the multi-grid view printed, if possible,” she said, adding that anything near the fovea will affect central quality of vision. Dr. Zhu said that patients with parafoveal epiretinal membranes on the outside of the macula or a scar just outside of the fovea could still be candidates for presbyopia-correcting IOLs in some cases. What to look for In general, Dr. Charles said cataract surgeons should be looking for macular degeneration, diabetic macular edema, central serous chorioretinopathy, epi- macular membranes, macular holes, and vitreomacular traction syndrome on OCT. He also said it’s important to assess the optic nerve for RNFL loss secondary to glaucoma. “Many macular disorders are invisible on retinal examination with the slit lamp and 90 diopter lens, Optos wide-angle imaging, [and] indirect ophthalmoscopy,” Dr. Charles said. Dr. Zhu said OCT can start picking up pathology in the vitreous. OCT can detect vitreous opacities, posterior vitreous detachment, or impending vitreous detachments. “You can diagnose that on OCT, depending on how the hyaloid face is attached. Sometimes it’s completely separated from the retina. If you see these thick vitreous opacities, that’s a sign that the vitreous might be turbid, and it may not give the best vision with a multifocal IOL,” she said. “The other thing is if you see an impending posterior vitreous detachment where the hyaloid is just detached at one part, but the other part is about to detach, you might want to counsel those patients about floaters postop because cataract surgery may induce them.” Dr. Zhu said this information is valuable for highly myopic eyes as well. If OCT shows the patient already had a PVD, their risk for retinal tears is lower. If the hyaloid face is still attached, cataract surgery could induce PVD, and they might be at higher risk for a postop retinal tear. “With highly myopic patients, I almost always send them to a retinal specialist for clearance before cataract surgery, just to make sure that we’re not missing any tears or holes in the periphery. Typically, if they have an axial length of greater than 25–26, I will send them for preop clearance. It’s not uncommon for the retinal specialist to find holes or severe lattice in the periphery that patients never knew about, and they laser them the same day,” Dr. Zhu said. At the macula, Dr. Zhu said she looks on OCT for epiretinal membranes, especially thick ones on top of the fovea that would be vision limiting, avoiding presbyopia-correcting lenses in these cases. She said she may even refer the patient to retina if she thinks their vision could be improved with treatment. In diabetics, she is looking for hard exudates and macular edema. If the patient has macular edema preop, she sends them to retina for anti- VEGF treatment before cataract surgery. She is also looking for AMD. A single drusen here and there might not impact vision, but confluent drusen throughout would signify the patient would not be a good candidate for a premium IOL and one who should be referred to retina. When looking at wet AMD, Dr. Zhu said there will be signs of intraretinal fluid, subretinal fluid, and/or the presence of choroidal neovascularization. “Those are patients you want to refer to retina right away, before cataract surgery, as they usually need an anti-VEGF injection because they can lose vision quickly. If the retina specialist can stabilize that part of the disease, they can have cataract surgery more safely,” she said. Other than that, Dr. Zhu said surgeons should be looking for scars from previous infection or trauma. Macular holes are another pathology that’s commonly seen. “Sometimes the patient will
CATARACT 12 EWAP DECEMBER 2022 have a partial thickness hole, which doesn’t affect vision much, but sometimes they have a full thickness hole that severely degrades vision and may benefit from surgical repair by a retina colleague, usually after cataract surgery,” she said. Dr. Zhu said she doesn’t typically get an OCT of the optic nerve as she relies more on biomicroscopy to examine the neuroretinal rim. If the patient has a large cup-to-disc ratio, she will get an OCT of the optic nerve head and a visual field to assess for glaucomatous changes. “OCT helps you differentiate between a glaucoma suspect and a patient who truly has glaucoma, or at least it helps you decide whether you need to refer to a glaucoma specialist to make that ultimate decision,” she said. “That diagnosis will affect your discussion on IOL selection with the patient.” EWAP Editors’ note: Dr. Charles practices at Charles Retina Institute Germantown, Tennessee. Dr. Zhu practices at NVISION Eye Centers Rowland Heights, California. Factoring astigmatism - from page 9 approval for toric IOLs for low levels of astigmatism. Whether it’s addressing the astigmatism on the cornea/limbus (incisional techniques, laser vision correction, or other methods) or with a toric IOL, Dr. Schallhorn said it’s important to improve the accuracy and predictability of correcting astigmatism. Dr. McCabe agreed with the results of this study and said in her own experience, small amounts of residual astigmatism can impact quality of vision, especially when using more sophisticated optics that split light. “I’ve been treating those low levels of astigmatism with my own nomogram until recently when we had more validated nomograms,” she said. “I know low levels of astigmatism will decrease the quality of distance vision with a diffractive optic. If I think it’s universally important to treat in the setting of diffractive optics, then I also think it’s important to address all levels of astigmatism to improve quality of vision at distance with all lenses. Therefore, I treat all low levels of astigmatism when I’m trying to reach a refractive target that allows for independence from glasses. I think that does provide better outcomes than we would get if we were not so focused on reducing residual astigmatism.” At this point in the evolution of delivering excellent outcomes with cataract surgery, it’s not reasonable to ignore astigmatism, Dr. McCabe said. “It’s a fundamental part of how we can improve the visual function and quality of vision for our patients.” EWAP Reference 1. Schallhorn SC, et al. Effect of residual astigmatism on uncorrected visual acuity and patient satisfaction in pseudophakic patients. J Cataract Refract Surg. 2021;47:991–998 Editors’ note: Dr. McCabe is Medical Director, The Eye Associates, Bradenton, Florida, and disclosed interests with Alcon, Bausch + Lomb, Carl Zeiss Meditec, Johnson & Johnson Vision, LENSAR, and Rayner. Dr. Schallhorn is Professor of Ophthalmology, University of California San Francisco, San Francisco, California, and disclosed no relevant financial interests. Editors’ note: Dr. Fram practices at Advanced Vision Care, Los Angeles, California. Dr. Kim is in private practice with Professional Eye Associates, Dalton, Georgia. Neither disclosed relevant financial interests. A ur rising, incidental finding from Dr. Schallhorn’s study was that leaving patients slightly hyperopic led to slightly better outcomes and patient satisfaction. “What it showed, which needs to be studied in greater detail, was that a low level of hyperopia resulted in better uncorrected vision and happier patients than if you leave those patients slightly myopic,” Dr. Schallhorn said. The important caveat is that it was in patients who wanted good distance vision in that eye; of course, this is not for patients in whom you’re targeting myopia. In those patients where the physician wants to hit zero refractive error and give the best uncorrected distance vision, the findings from the study suggested that leaving patients slightly hyperopic is better than leaving them slightly myopic, he said, further clarifying that this is in reference to when the surgeon is deciding between lens power options with half diopter increments in which the estimated postop refraction straddles emmetropia. Previously, he would default to leaving the patient slightly myopic. He reiterated that this needs to be investigated further to understand in greater detail what it means and how should it drive practice. The size of the study was its strength, Dr. Schallhorn said. It requires large sets of data to accurately assess patient satisfaction and patient-reported outcomes because of the inherent variability in patient responses. Dr. McCabe said that she usually aims for as close to plano as possible. “I’ve found that allows the patient to have the best quality of vision,” she said. “Unfortunately, right now, we don’t have a way of targeting in less than half diopter increments of power.” Dr. McCabe said that when it’s within a half diopter, she generally will target closest to plano or a little on the myopic side, but she added that there are certain optics that work better with a little residual hyperopia, like the Synergy (Johnson & Johnson Vision).
CATARACT EWAP DECEMBER 2022 13 Dr. Fram performs the lock-in treatment with the Light Delivery Device (RxSight). Source: Nicole Fram, MD Contact information Fram: info@avceye.com Hoopes: pchj@hoopesvision.com Nikpoor: drneda@alohalaser.com Solomon: jonathansolomonmd@gmail.com T he Light Adjustable Lens (LAL, RxSight) is still a relatively new IOL technology, offering the ability to adjust the refractive settings of the lens after implantation with “lock-in” treatments. In this article, several physicians discussed their decision to bring it into practice, implementation considerations, and overall impressions. Nicole Fram, MD Dr. Fram decided to bring the LAL into her practice when she realized she had a more than 20% post-LASIK/PRK patient population needing cataract surgery. Even the best formulas reach a refractive target +/–0.50 D 69–79% of the time, she noted.1–5 “The promise of a technology that we could adjust after surgery Adopting the Light Adjustable Lens: Implementation and personal experiences by Ellen Stodola Editorial Co-Director to meet the refractive goals was exciting,” she said. “In addition, our primary strategy for independence from glasses in this patient population was mini-monovision, as the EDOFs and multifocals on the market at the time had significant diffractive dysphotopsia.” Dr. Fram said workflow adjustments to accommodate the LAL were relatively easy. The patients had all appointments scheduled from the start and understood how long they would need to be in the office. It is important to explain upfront that this technology is not for all patients, particularly if they are from out of town or have a low threshold for wait times. Dr. Fram said she had no reservations about implementation, except that prior to the ActivShield This article originally appeared in the September 2022 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. technology, she had one patient develop a central zone and poor vision due to non-compliance with the protective glasses. “Fortunately, the development of ActivShield has decreased this risk, and we have not seen a single case since its implementation.” It’s important to tell the patient that the strategy for more spectacle independence is blended monovision. “They need to understand the 80/20 rule—80% of what they do on a day-to-day basis will be spectacle-free. However, this is still monovision, and when driving at night or reading a medicine bottle, they may need glasses.” Monovision in the pseudophake is different than monovision with LASIK/ PRK or contacts, as their natural crystalline lens may allow for some accommodation. Dr. Fram explains to patients that the LAL technology can more effectively hit targets and customize vision, particularly in the post-corneal refractive surgery population. Dr. Fram noted there is not currently an IOL that exactly counterbalances the higher order aberrations of the cornea and/or accommodates. “This is the missing advancement in the world of lens replacement,” she said. “This technology may solve the effective lens position issue by providing postoperative
CATARACT 14 EWAP DECEMBER 2022 adjustment capabilities. However, it does not fully counteract these aberrated corneas to achieve better quality of vision.” She added that the EDOF version will be interesting, if it does not increase the dysphotopsia profile. Phillip Hoopes Jr., MD Dr. Hoopes has been using the LAL technology for 8–9 years, from the FDA trial through its launch, giving him a unique perspective. Hoopes Vision has a research center, he said, so it’s able to get involved in a lot of industry research and studies, including the LAL FDA study. Once the product was approved in 2019, his practice began using it. Dr. Hoopes said the LAL involves a change from the usual mindset. With traditional implant technology, most of the work is done before surgery. You make your measurements, you put the implant in, and you’re stuck with the results. “The Light Adjustable Lens is a crossover into the idea of refractive cataract surgery.” He said physicians who have done refractive surgery likely don’t have to change their routine too much in order to incorporate the LAL. Postop patients wear UV- protective glasses for up to 5 weeks, Dr. Hoopes said. The process begins by sitting down with the patient over multiple visits, anywhere from three to five extra visits. Traditionally, Dr. Hoopes sees cataract patients at 1 day, 1 week, and 1 month postop, but with the LAL, the work starts at 1 month postop. Patients must be informed preop about the extra visits and that they must come in several times a week, he said. “The promise of the LAL is to have a product where a month after surgery you can fine tune and personalize results to the patient,” he said. However, a challenge is you must pick the right patients. For example, patients’ eyes must be able to dilate to a certain degree, and if they can’t, they are not eligible for this procedure, Dr. Hoopes said. The light adjustments are not any more difficult than doing a YAG capsulotomy, but the patient must be able to hold steady for 2 minutes. Another challenge is the potential for changes to the eye. “The promise of the lens always was that we could fine tune the results accurately and by the end of the process have patients completely corrected in their vision,” Dr. Hoopes said. “The truth is there’s still the possibility of having small prescriptions even at the end of light adjustment. We know people can still change 2–4 months down the road after cataract surgery just by how the capsule heals. Even the LAL doesn’t prevent the possibility of more long-term changes to prescription, such as astigmatism over time.” While there’s no surgical learning curve, Dr. Hoopes stressed the importance of communication about the treatment process. “As long as I communicate the time period with the patient, the expectation of the work needing to be done a month later, almost every LAL patient has been excited about the technology and willing to undergo the lengthier process. They feel like they have a say in their surgery and outcome.” Dr. Hoopes noted the ActivShield advancement, which allows patients some flexibility with the ultraviolet glasses, but he said even before this update, he had very few cases of patients complaining about wearing them. He still recommends patients wear the glasses as much as possible. One future advancement Dr. Hoopes hopes to see is the ability for physicians to make the decision to lock a patient in. Currently, it’s the software and Editors’ note: Dr. Fram practices at Advanced Vision Care, Los Angeles, California. Dr. Kim is in private practice with Professional Eye Associates, Dalton, Georgia. Neither disclosed relevant financial interests. Though the need to remove the LAL is infrequent, it can prove challenging, particularly if the lens has already been locked in. The LAL becomes brittle after it has been treated and locked in, Dr. Fram said. “In the previous generation of the LAL without ActivShield, when trying to stabilize the lens with serrated forceps, it would break into tiny pieces.” Dr. Fram suggested that the best approach is to provide counter traction with a Sinskey hook and use serrated scissors that can hold the lens while cutting. “I have also found that enlarging the main incision to 3.5 mm is helpful, as the lens is silicone and thick and may be difficult to get out of a sub-3 mm incision.” Removal after lock-in is a rare occurrence with the development of the ActivShield, Dr. Fram said, “however, if you put an IOL in, you should know how to remove it safely in the circumstance that it becomes necessary.” Dr. Solomon noted that he has only had to do one removal before the lens was locked in. During one of his insertions, the injector system caused inadvertent damage to the lens, and he had to explant it immediately. He mentioned that it does require attention because it’s a gummy, silicone lens. It’s relatively soft at that stage, so be prepared by using good instrumentation, he said. If you have to remove the lens
CATARACT EWAP DECEMBER 2022 15 Editors’ note: Dr. Fram practices at Advanced Vision Care, Los Angeles, California. Dr. Kim is in private practice with Professional Eye Associates, Dalton, Georgia. Neither disclosed relevant financial interests. Dr. Fram offered the following recommendations when first beginning with the LAL. 1. Picking the IOL power: Pick on the first hyperopic side of plano so you can add in power and allow for an effective extended depth of focus by changing the spherical aberration profile centrally. In the non-dominant eye, adjust to effectively cause more negative spherical aberration and increase the depth of focus, she said. “However, if this is a post-LVC or RK eye with an already aberrated cornea, use your normal post-LASIK formulas and pick as you would to avoid big misses in refractive target and large treatments to get to plano.” 2. Higher order aberrations and expectations: Surgeons should be sure to look at Placido imaging and ablation pattern to give proper counseling of the postoperative outcome. The LAL adjustments are not wavefront guided, and if the RMS is high and/ or the Placido imaging is distorted, the patient’s best vision may be with a scleral contact lens. 3. Post-hyperopic LASIK vs. post-myopic LASIK: The hyperopic LASIK patient is challenging in that the K readings are often a moving target despite multiple measurements. This makes the ability to adjust postoperatively ideal in many ways. However, in an eye that already has negative spherical aberration on the corneal topography, it may not be ideal to add a negative spherical aberration IOL. In theory, surgeons want to place an IOL with a neutral or positive spherical aberration in these patients to counteract the negative spherical aberration of the cornea. “In our practice, we perform LAL on hyperopic LASIK patients with neutral to slightly positive spherical aberration measured by wavefront aberrometry patterns to avoid potential issues with image quality,” she said. “Alternatively, in patients with myopic LASIK ablation patterns we are comfortable using this technology as long as the ablation is centered and the Placido imaging is regular.” 4. Intraoperatively: Practice putting in three-piece IOLs, making the incision at least 2.75–3.0 mm at first to avoid Descemet’s detachments when positioning, centering the rhexis on the visual axis, 4.8–5.0 mm, cleaning the posterior capsule well to avoid delay in LAL treatment due to fibrosis of the capsule, and polishing the anterior capsule to avoid capsule contraction, placing the haptics at 6 and 12 o’clock for better IOL stability and less striae in the capsule. When first starting with the LAL technology the light adjustable device that determines when it’s time to do the lock-in treatment. However, he noted that in some cases, he’s had patients who were happy with their vision before the lock-in process. “I would love the opportunity as the surgeon to be able to bypass treatment and make the decision to lock in the patient right now if the patient is happy with their vision. Now I might have to do 1–2 small adjustments or even sham adjustments,” he said. Sometimes these small adjustments can even make patients less happy with their vision. A future option to delay adjustments several months could also be advantageous, Dr. Hoopes added. Neda Nikpoor, MD Dr. Nikpoor said that her partner, Alan Faulkner, MD, was one of the first to adopt the LAL upon launch and the first to bring the technology to Hawaii. Dr. Nikpoor started using the LAL in February 2020. Dr. Nikpoor implanted the lens in her first set of patients right before the pandemic. “During this time, we were still seeing our postops, and it gave us some time to play around with the LAL,” she said. “The timing was perfect for us to integrate something new and have time to understand it and follow those patients closely.” It’s the only lens that Dr. Nikpoor said she wants to put in post-refractive patients. “For a practice that does high-volume laser vision correction, it’s a must-have.” She added that some patients in her practice have had RK or LASIK years ago and are coming back. You want to be able to offer them the best technology designed for their eye, she said. From a practice growth perspective, it gives you a competitive edge to be first in the market, Dr. Nikpoor added. “We’ve gotten referrals from other cataract surgeons because patients are asking about it.” The LAL is also a great option for virgin eyes, she said. They did a review of their cases and found that there were high levels of spectacle independence with a mild amount of blended vision. On average across all patients, the range of vision was similar to an extended depth of focus lens. “The range and quality of vision are excellent, making LAL a great option for any patient,” Dr. Nikpoor said. One obstacle to adoption is figuring out the workflow because of the extra visits, and the visits take a while, Dr. Nikpoor said. In her practice, this involved finding time on the schedule to do adjustments twice a week and training technicians. “We would have
CATARACT 16 EWAP DECEMBER 2022 a specific tech who was good at assessing dilation, getting patients dilated, programming, being with us for the treatments, etc.,” she said. “We have patients coming in clusters of three, so we have three patients getting refracted close to each other and getting dilated together, and we found that to be useful.” Dr. Nikpoor said the LAL is an “easy sell” with post-refractive patients. “I explain to them that even with all the measurements we take, we’re still going to be off 10–20% of the time,” she said. “I show them their scans, and I show them why their RK or LASIK makes it challenging to determine the correct lens power.” For other patients, Dr. Nikpoor will still explain how it’s necessary to enhance any diffractive or premium lens 10–15% of the time. Then she explains the alternative of putting a lens into the eye where all the adjustments are built into part of the process and any fine tuning can be done without an additional surgery. She added that the LAL is a desirable option for some patients who don’t know what they want and find it stressful to commit. Dr. Nikpoor said the ActivShield technology has been a helpful advancement. Though she noted that she’s only had one patient who was not compliant with the glasses before ActivShield, she did have to end up exchanging that patient because of stray UV light. It was a difficult case, Dr. Nikpoor said, but when she did the exchange, the ActivShield technology was available, so this was one of her first patients with the update. Dr. Nikpoor is eager to see the ability to add or remove extended depth of focus in the future. “Even though it’s a monofocal, it gives you a little more extended depth of focus than a typical monofocal, and when you do the first adjustment in a myopic direction with a myopic target, on the near eye, you get even more extended depth of focus,” she said. “But I think they will figure out a way to induce even more and give us the ability to induce it or take away if we want to.” Another exciting future advancement is the potential for the company to create a custom light adjustment profile that would help offset some corneal aberrations, Dr. Nikpoor said. Jonathan Solomon, MD Dr. Solomon was aware of the LAL technology for a number of years before deciding to use it in his practice. “I was eager to get my hands on the technology with the idea that it would T he light adjustable lens (LAL, RxSight) has been around for many years and is undergoing a resurgence in the United States. Drs. Fram, Hoopes, Nikpoor, and Solomon are to be congratulated for exploring this technology and using it in their practices. Dr. Fram rightly points out that 20% of her cataract patients these days have had prior LASIK or PRK. This is very similar in my practice and I’m sure it is the same in many practices in Asia. These are demanding patients but also quite motivated and I find them a pleasure to deal with because they have often been very happy with their previous corneal refractive surgery and want to revisit good unaided vision after cataract surgery. The first thing to note is that not all post LASIK patients are the same and each cornea needs to be assessed on its merits. The authors highlight the logistic challenges in their practices of multiple visits and chair time in explaining the value of the light adjustable lens. They also lament the fact that it is only available in a monofocal type lens at present. It is clearly an evolving technology. Dr. Hoopes rightly concedes “the truth is there is still a possibility of having small prescription errors at the end of light adjustment”. So it is not a perfect technology and cannot be promised as such. It seems to me that the light adjustable lens is a United States phenomenon and has not achieved significant traction outside the United States. Why would this be so? • One issue is cost; it is an expensive lens and there are good alternatives. • The second is accuracy of current cataract surgery. Modern biometry with ocular surface optimization and improved formulae have improved our ability to hit the target in normal eyes and also in post refractive eyes. • We also have good technology to enhance post cataract refractive errors with either PRK or LASIK. Often these are very small adjustments and PRK is quite easy to perform and does not induce further corneal aberrations. In many parts of the world, there is also the option of a secondary sulcus placed intraocular lens, such as the Rayner Sulcoflex. This is my preferred option when there is a post cataract refractive error, if corneal laser is not appropriate. These have a long track record, are easy to perform as a secondary procedure some months after the original cataract surgery, and have an excellent accuracy and safety profile. My personal view is that the light adjustable lens will remain a United States phenomenon and its value to surgeons and patients will decrease when a good quality secondary sulcus intraocular lens is available in the United States. This may be some time away. Of course, the light adjustable lens technology may evolve to provide an EDOF or multifocal type optic and it may eventually be possible to reverse aberrations by adjusting the light adjustable lens. If so, the LAL may have a role beyond a niche procedure in the USA. Editors’ note: Dr. Lawless is a consultant for Alcon and Carl Zeiss. Michael LAWLESS, MD Associate Professor, Vision Eye Institute, Sydney 4/270 Victoria Ave., Chatswood, Australia michael.lawless@vei.com.au ASIA-PACIFIC PERSPECTIVES
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