EyeWorld Asia-Pacific September 2023 Issue

eyeworldap.apacrs.org The Asia-Pacific Association of Cataract and Refractive Surgeons ASIA-PACIFIC Vol. 19 No. 3 September 2023 www.eyeworldap.apacrs.org

2 EWAP SEPTEMBER 2023 Preliminary Program overview 30 MAY 2024 (THU) 31 MAY 2024 (FRI) 1 JUNE 2024 (SAT) 07:30hrs onwards REGISTRATION 09:00 – 10:30hrs MASTERCLASSES (S1) CHINESE SYMPOSIUM FREE PAPERS 07:30 – 08.45hrs (S5) IIIC LECTURES The Perfect Save! (S6) BITS & BYTES FOR THE FUTURE Digital Ophthalmology (S7) CHINESE SYMPOSIUM 09:00 – 10:30hrs OPENING CEREMONY & APACRS LIM LECTURE 07:45 – 09:15hrs (S13) CATARACTS & CONFUCIUS Rules to Success (S14) PANDERING TO PRESBYOPIA (S15) CHINESE SYMPOSIUM 09:30 – 12:30hrs (S16) LIVE SURGERY/SURGICAL VIDEO SYMPOSIA 10:30 – 11:00hrs Tea Break 11:00 – 12:30hrs MASTERCLASSES (S2) CHINESE SYMPOSIUM FREE PAPERS 11:00 – 12:30hrs (S8) PATHWAYS TO PRECISION & PERFECTION Combined Symposium of the Cataract & Refractive Societies (CSCRS) – APACRS, ASCRS & ESCRS FREE PAPERS 11:00 – 12:30hrs LIVE SURGERY/SURGICAL VIDEO SYMPOSIA FREE PAPERS 12:45 – 13:45hrs INDUSTRY LUNCH SYMPOSIA 14:00 – 15:30hrs MASTERCLASSES (S3) CHINESE SYMPOSIUM FREE PAPERS 14:00 – 15:30hrs (S9) HARMONY IN HAzE Navigating Cataract Complications with Yin & Yang (S10) BLACK OR WHITE Controversies in Refractive Surgery (S11) CHINESE SYMPOSIUM FREE PAPERS 14:00 – 15:30hrs (S17) KNOW YOURSELF, KNOW YOUR CHALLENGES Challenging Cases (S18) GREEN SHOOTS What’s New in IOLs? (S19) CHINESE SYMPOSIUM FREE PAPERS 15:30 – 16:00hrs Tea Break 16:00 – 17:30hrs MASTERCLASSES (S4) CHINESE SYMPOSIUM FREE PAPERS 16:00 – 17:30hrs (S12) FILM FESTIVAL SYMPOSIUM & AWARDS CEREMONY 16:00 – 17:30hrs (S20) WISDOM FROM THE KUNG FU MASTERS Top Cataract Surgery Tips AFTERNOON MORNING

EWAP SEPTEMBER 2023 3 EDITORIAL EyeWorld Asia-Pacific • September 2023 • Vol. 19 No. 3 Graham Barrett Chief Medical Editor EyeWorld Asia-Pacific • China • Korea • India M aking Practice Perfect” touches on many aspects of the various areas of anterior segment surgery. "Making Practice Perfect for Post-refractive cataract patients" emphasizes the importance of paying attention to every detail of patient care when performing cataract surgery. This is important in both straightforward and challenging cases including patients who have had previous refractive surgery and keratoconus. This attention to detail is what distinguishes a merely competent surgeon from one who consistently achieves excellent outcomes. In striving for perfection, we are assisted by improvements in technology as highlighted in the article recalling the introduction of YAG laser capsulotomy which revolutionized the management of posterior capsular opacification. Similarly, the selection of lenses in patients who have had previous refractive surgery is less uncertain with the availability of instruments that are able to measure the posterior cornea and improved formulae. I think we all would acknowledge how the creation of flaps during LASIK has improved with the availability of femtosecond lasers and the introduction of MIGS has offered new opportunities for patients with glaucoma. All procedures require surgical skill but one of the major changes that has occurred over the years is the important role of surgical planning and IOL selection. Where before this often consisted of simply circling a lens on a biometer printout, today it requires considered thought, multiple devices, and an understanding of the specific formulae required depending on the context. I have been fortunate to have supervised many fellows over my career and one question that I have often been asked is what distinguishes a surgeon regarded as excellent from one of average ability. My answer is that surgical expertise is essential but a continued focus on striving for perfection in all aspects of care plays an equally important role. This issue is a timely reminder of the key role that this philosophy plays in providing personal satisfaction as well as better outcomes for our patients. I hope you find the articles interesting and helpful in your own practice. “

4 EWAP SEPTEMBER 2023 30 MAY - 01 JUNE 2024 chENgdU, chiNA MASTERCLASSES Time room 2 room 3 room 4 09:00 – 10:30hrs MASTERCLASS (MC1) mASTeriNG ioL FiXATioN MASTERCLASS (MC2) mASTeriNG ViTreCTomY For ANTerior SeGmeNT SUrGeoNS MASTERCLASS (MC3) mASTeriNG miGS ComPLiCATioNS TeA BreAk 11:00 – 12:30hrs MASTERCLASS (MC4) mASTeriNG CHoPPiNG & Pre-CHoPPiNG MASTERCLASS (MC5) mASTeriNG eNDoTHeLiAL kerAToPLASTY MASTERCLASS (MC6) mASTeriNG PHAkiC ioLS iNDUSTrY LUNCH SYmPoSiA 14:00 – 15:30hrs MASTERCLASS (MC7) mASTeriNG BiomeTrY MASTERCLASS (MC8) mASTeriNG reFrACTiVe SUrGerY ComPLiCATioNS MASTERCLASS (MC9) mASTeriNG ANTerior SeGmeNT oCULAr TrAUmA TeA BreAk 16:00 – 17:30hrs MASTERCLASS (MC10) mASTeriNG ToriC ioLS MASTERCLASS (MC11) mASTeriNG PAeDiATriC CATArACT SUrGerY MASTERCLASS (MC12) mASTeriNG PHACo FLUiDiCS

EWAP SEPTEMBER 2023 5 CATARACT 08 Making Practice Perfect for Posterior capsulotomy: History of using the YAG laser and best practices by Ellen Stodola 12 Making Practice Perfect for Post-refractive cataract patients by Liz Hillman 16 Making Practice Perfect for IOL exchange by Liz Hillman CONTENTS 03 Editorial 21 A look at violet-blocking and blue light-filtering technology by Ellen Stodola 25 Making Practice Perfect – The refractive postop experience by Ellen Stodola CORNEA 32 Making Practice Perfect – Special considerations for DMEK in glaucoma patients by Liz Hillman 35 Making Practice Perfect – Blepharitis: Types, presentation, and treatment by Ellen Stodola 40 What would you do with these irregular cornea cases? by Liz Hillman GLAUCOMA 42 Making Practice Perfect – Navigating the world of goniotomy/trabeculectomy and canaloplasty by Liz Hillman REFRACTIVE 19 Equipment updates advancing refractive surgery by Liz Hillman 44 How to handle uveitic glaucoma by Ellen Stodola 47 Making Practice Perfect – Optimizing the glaucoma eye for surgery by Liz Hillman NEWS & OPINION 50 How physician leaders can harmonize with their management team by Corinne Wohl, MHSA, COE, and John Pinto 52 Collaborative strategies to reduce costs and waste in the operating room by Cathleen McCabe, MD 55 ESCRS Clinical Trends Survey 2016 - 2021 by Luke (Jin Kyun) Oh, MD 57 Capsular tension ring against inthe-bag dislocations by Christopher Long, MD, Shaunak Bakshi, MD, Ian Christensen, MD, Abinaya Thenappan, MD, Austin Bohner, MD MAKING PRACTICE PERFECT

6 EWAP SEPTEMBER 2023 The 36th APACRS annual meeting will return to China, the most populous nation in the world where we expect an even larger crowd. The hunger for more knowledge and quality education in our delegates means that we always strive to present an up-todate yet relevant and practical scientific meeting. This 36th APACRS meeting jointly organized with the 24th CSCRS (Chinese Society of Cataract & Refractive Surgery) annual meeting promises to deliver a great learning experience in 2024. MASTERCLASSES Covering the most relevant and focused topics and conducted by some of the world’s leading surgeons! Expect the hotest topics in ophthalmic surgery today, where you will learn to master IOL Fixation, Vitrectomy for Anterior Segment Surgeons, MIGS Complications, Chopping & Pre-Chopping, Endothelial Keratoplasty, Phakic IOLs, Biometry, Refractive Surgery Complications, Anterior Segment Ocular Trauma, Toric IOLs, Paediatric Cataract Surgery, and Phaco Fluidics. APACRS LIM LECTURE The APACRS LIM Lecture is the highest award of the society. Since 1991, outstanding ophthalmologists who have made extraordinary contributions to the development of cataract and refractive surgery have been invited to deliver this prestigious lecture. Join us as we listen to Dr. Shin Yamane, MD, who pioneered the Yamane Technique, a modification of sutureless intrascleral IOL fixation delivers the APACRS LIM Lecture 2024. Stay tuned for more updates! APACRS FILM FESTIVAL The APACRS Film Festival entertains and educates, creatively displaying new innovations and breakthroughs in anterior segment ophthalmic surgery. Don’t miss this exciting session on the evening of Friday, 31 May 2024. COMBINED SYMPOSIUM OF CATARACT & REFRACTIVE SOCIETIES (CSCRS) PATHWAYS TO PRECISION & PERFECTION This combined symposium of the three leading cataract and refractive societies (APACRS, ASCRS, and ESCRS) will take a critical look at precision and perfection in Light Adjustable IOL vs. Formulae, Phaco vs. Femto, and SMILE vs. LASIK. SCIENTIFIC SYMPOSIA Exciting symposia covering Navigating Cataract Complications, Controversies in Refractive Surgery, Challenging Cases, What’s New in IOLs? and IIIC Lectures – The Perfect Save! [NEW] BITS & BYTES FOR THE FUTURE – Digital Ophthalmology In this new age, digitization is all pervasive in all walks of life and so it is in cataract and refractive surgery. Join us as we look into the benefits and limitations of digital technology in our practice. WISDOM FROM THE KUNG FU MASTERS – Top Cataract Surgery Tips Some of the most renowned cataract surgeons each offer practical cataract surgery tips that surgeons can use immediately on their next visit to the operating theatre. Program HigHligHts Wisdom From The Kungfu Masters

EWAP SEPTEMBER 2023 7 CORNEA 34 Innovations in the treatment of endothelial dysfunction by Ellen Stodola GLAUCOMA 37 Combining MIGS procedures by Ellen Stodola 40 MicroPulse for the anterior segment surgeon by Liz Hillman 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: EyeWorld Asia-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 8 EWAP SEPTEMBER 2023 Following cataract surgery, patients may experience blurry vision. A posterior capsulotomy with the YAG laser is often employed by physicians as a solution to help patients achieve their desired vision. “A YAG capsulotomy has to be one of the most commonly performed procedures for a cataract and refractive surgeon,” said Robert Weinstock, MD. “Fortunately, it’s a safe, easy, and efficient technology.” Prior to YAG capsulotomies and the invention of the YAG laser, this was a much more challenging condition because it required going back into the eye and doing a surgical procedure, with the risk of infection. In addition, when you rip the capsulotomy, it’s not controlled, vitreous can come forward, and there can be PVD and retinal detachment, Dr. Robert Weinstock said. “I think the YAG was one of the greatest inventions in the history of ophthalmology,” he said. “It has made our lives so much better having the technology.” Dr. Robert Weinstock noted that his father, Stephen Weinstock, MD, was one of the first surgeons in the U.S. to have a YAG laser. “When I started practicing 20 years ago, he taught me how to become an artist with the YAG.” We’re trained to put this Contact information Nattis: asn516lu@gmail.com Robert Weinstock: rjweinstock@yahoo.com Stephen Weinstock: smweye@gmail.com Making Practice Perfect for Posterior capsulotomy: History of using the YAG laser and best practices by Ellen Stodola Editorial Co - Director This article originally appeared under the title “Posterior capsulotomy: history of using YAG laser and best practices” in the July 2023 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. contact lens on the eye, use low power, and punch out the capsule. “But for standard YAGs, [my father] taught me that you don’t need to put a lens on the eye. You can use higher power and do a couple of shots with the laser, and it splits it open without creating a big, punched out posterior capsule that floats around in the vitreous,” he said. “We use higher power with less shots now, which is much faster. … It’s become a much less invasive procedure. This makes it more efficient and takes only a couple of seconds.” Dr. Stephen Weinstock discussed his experience with YAG, noting that he estimates around 30–40% of patients develop PCO and need a YAG capsulotomy, no matter the precautions taken during surgery. It’s difficult to get 100% of lens epithelial cells removed during a cataract procedure, he said. Earlier YAG capsulotomies were more traumatic and less refined, he said. It wasn’t as powerful or fine-tuned, and there were slightly more complications (the main complication was lens dislocation into the vitreous). “Physicians were trying to figure out how to reduce the need for posterior capsulotomy,” Dr. Stephen Weinstock said. “As the laser was refined, I found that it was much easier to perform it PCO in a patient with a multifocal IOL needing a YAG to improve vision. Source: Robert Weinstock, MD

CATARACT EWAP SEPTEMBER 2023 9 Anterior capsule phimosis requiring an anterior capsule YAG. Open posterior capsule after YAG capsulotomy. Source (all): Robert Weinstock, MD with precision so that we could guide how large of an opening we were going to create.” He said he’s seen very few complications in the past 15–20 years. “Prior to that, when I was doing cataract surgery, I used to spend a lot of time during the case vacuuming the posterior capsule,” he said. “I started thinking it was foolish to do this when there are so few complications post - YAG. “It used to be difficult when I would see a patient who had a posterior capsular cataract because many of them did not come off the posterior capsule,” Dr. Stephen Weinstock said. “They could require needling of the posterior capsule and/or a second procedure, with a higher risk profile and worse outcomes. When the YAG was invented, it was like a breath of fresh air because we didn’t have to worry about going back into the eye. It was a paradigm shift in our approach to cataract surgery,” he said. “I think this was one of the great advancements in surgery, and it led to other types of lasers being developed for glaucoma and other conditions.” Alanna Nattis, DO, uses the YAG laser frequently in her practice. “I do several per week, whether on my own patients or those referred after having cataract surgery several years ago,” she said. “It’s a successful and straightforward procedure for our patients and very gratifying because it restores vision to what it was right after they had cataract surgery.” She said the literature indicates that about 20–50% of patients will have PCO after surgery. A lot of surgeons polish the posterior capsule, and that can help prevent PCO, but sometimes it doesn’t, she said. “I like to explain to patients that it’s almost like scar tissue has formed, and it can make the vision blurry. It can give them glare and halos, and if that happens, we can do a laser procedure to help clear the central visual axis again,” she said, adding that it only takes a few minutes to do the procedure, and she does not use a contact lens with the YAG laser. “I aim the laser at the posterior capsule and try to make a large symmetric opening in the central visual axis of the posterior capsule with as little energy and as few shots as possible,” she said. While the YAG laser procedure is not high risk, Dr. Nattis noted that there is a small risk of retinal injury and retinal detachment. “That is not common today with the lasers that we have, [but] I do always counsel my patients about that, especially in those who have had prior retinal detachments.” Dr. Nattis said she doesn’t

10 EWAP SEPTEMBER 2023 CATARACT use a topical anesthetic because the procedure is not painful, there’s nothing touching the eye when doing the procedure, and no incisions are made. “I do tell the patients they will be blurry for 30–60 minutes or longer after the laser, but by that evening or the next day, their vision will clear up significantly,” she said. “I warn patients that it might make their floaters more noticeable.” The techniques that have been developed to prevent opacification are great, Dr. Robert Weinstock said. For example, the square-edge lenses are proven to reduce the migration of lens epithelial cells, which are often the source of the opacification. Good cortical cleanup with I/A and polishing of the capsule is another technique that can slow the process of capsular opacification, he said. However, even with these options, the majority of patients will ultimately need a YAG capsulotomy. There are some patients who have fibrosis of the capsule itself during cataract surgery. Sometimes you can polish off some of the opacity at the posterior capsule. Other times patients have had previous surgery, like retina surgery, and there is scarring in the vitreous and posterior plaques of fibrosis on the capsule. Those can’t be removed at the time of cataract surgery, so those patients require a YAG fairly quickly because once the cataract is gone and the new lens is in, it’s cloudy, Dr. Robert Weinstock said. “I’m not a fan of doing a posterior capsulotomy at the time of cataract surgery,” he said. “I think it introduces the potential for vitreous to come through into the anterior segment, and the YAG is so safe and easy. In my opinion, it’s easier to stage the procedures.” Dr. Robert Weinstock said that he will tell patients after surgery that the capsule was opacified, and the safest move is to let the eye heal for a month or so, then do the YAG capsulotomy. Dr. Robert Weinstock noted that a lot of lenses in the premium cataract surgery arena are sensitive to PCO. The performance of these lenses can be degraded by small amounts of PCO, whereas patients might not notice as much with a monofocal. “Some surgeons are turning to earlier YAGs in the premium IOL patients to improve the performance of the IOL,” he said. The other thing to note is even with the best biometry and the best surgical technique, there are still cases of patients who are off target after surgery. When these patients have paid for premium cataract surgery, your goal is to get them out of glasses, and sometimes you must come back and do a surface ablation to fine tune the vision. Dr. Robert Weinstock said he typically likes to do the YAG capsulotomy first because there can be small changes of the refraction after the YAG. “There can be minor changes to the lens position after you release some of the tension on the posterior capsule,” he said. “In my mind, it’s best to do the YAG capsulotomy first, let the eye heal for a couple weeks, then bring the patient back, refract them, and move on to PRK or LASIK to fine tune the vision and reduce any residual refractive error.” For the routine YAG, it’s standard, he said. When you don’t put a contact lens on the eye, you need more energy. The contact lenses focus the energy, and you need less energy. But if you crank up the energy and don’t put the contact lens on, it’s just as effective, he explained. “There are cases where we see contraction of the anterior capsule coming over the optic, and sometimes it’s even squeezing the lens and causing it not to be in the right location inside the eye,” he said. “If you use the YAG to make little nicks in the anterior capsule, it can release the tension of the capsule and let the lens [settle into] a more natural position.” Dr. Robert Weinstock cautioned against doing a YAG too early, particularly in patients having problems with multifocals or EDOF lenses. The issue could be neuroadaptation, he said, but some jump to doing a YAG early. The patient might end up needing the lens explanted, depending on how they adapt, he said. “It’s a more complicated and risky procedure to explant a lens if the capsulotomy has already been done by the laser because there is a continuation 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. Robert Weinstock discussed another way he uses the YAG laser. He said it can be used for breaking up vitreous strands behind the capsule in the anterior vitreous. It is a YAG laser, but the light focuses with that laser. “You can focus a little more precisely into the vitreous. For people who suffer from anterior vitreous floaters that are stuck in their vision and are causing haze, we do YAG laser vitreous photolysis,” he said. That often helps a patient who suffers from bad floaters. “We will use the YAG because of its optics to disrupt some of these fibrotic strands of vitreous that are right in the vision, and it will break them up, much like you break up the capsule, then gravity will help them drift out of the way,” he said. “We’ve had great success in avoiding vitrectomies for floaters.”

CATARACT EWAP SEPTEMBER 2023 11 of the eye to where the vitreous can come forward now that there is a hole in the posterior capsule,” he said. Dr. Nattis recommended avoiding the YAG laser if the patient has a cloudy cornea or if you don’t think you’re going to be able to perform the procedure properly. Sometimes you can aim the laser beam so you can see the posterior capsule tangentially and get around a small opacity at the cornea level, she said, but you want to be sure you’re doing a complete procedure and not a partial YAG. Ultimately, these patients with anterior segment haze or scarring may require a surgical capsulotomy if visualization for a laser capsulotomy is poor. “We always check eye pressure before and after doing the laser because in some patients, it can spike,” she added. Dr. Nattis said there’s no specific timeframe within which to do a YAG; it’s when the patient becomes symptomatic. “We tend to do YAG capsulotomies earlier in patients who have multifocal or trifocal IOLs because those patients tend to be more sensitive to glare and halo,” she said. While she doesn’t do surgical posterior capsulotomy often, Dr. Nattis said this might be used for patients who can’t sit at the laser or who find it hard to maintain gaze in a certain direction. Dr. Robert Weinstock said he performs surgical capsulotomy in rare situations. He said he used this approach when he was doing a lot of Crystalens (Bausch + Lomb) implantations because it was prone to capsular contractions, Z-syndrome, and major displacements of the IOL where “you needed to do an IOL exchange and sometimes you couldn’t do that exchange without some damage to the capsule, but you had to get the lens out of there.” He said there are some situations with IOL exchange where the physician might have to do a posterior capsulotomy with a vitrector to have a controlled hole. This is usually avoided because the YAG laser is so easy and safe and is a much more controlled procedure, he said. “One thing that I learned during residency and in fellowship is sometimes it’s easy to miss a little thread of the posterior capsule that might be still attached to the rest of the capsule that you’ve already lasered, and patients may come back and say, ‘I still see something floating in my vision,’” Dr. Nattis said. “Before I tell the patient the procedure is complete, I’ll do a once over to make sure there are no posterior threads hanging on. You can go in and do a touch-up, but it’s good to save yourself and the patient from doing that.” EWAP Editors’ note: Dr. Nattis practices at SightMD, Babylon, New York, and has interests with Alcon. Dr. Robert Weinstock practices at The Eye Institute of West Florida, Largo, Florida, and has interests with Johnson & Johnson Vision, Alcon, Bausch + Lomb, and LENSAR. Dr. Stephen Weinstock practices at The Eye Institute of West Florida and declared no relevant financial interest. T he good news is that the incidence of development of posterior capsular opacification (PCO) and YAG capsulotomy is decreasing as surgical techniques and IOL materials and design have improved over the years. Hydrophobic material and square edge have been shown to reduce PCO formation. But it still remains a significant aftereffect of cataract surgery. In the Asia-Pacific region, the cataract is increasingly seen at younger age. Many of these cataracts have posterior subcapsular plaque. These “intraoperative” posterior capsule plaques are also seen in eyes with uveitis, advanced long-standing as well as mature cataracts. Capsule polishing can remove residual leftover fibers, but these plaques cannot be removed by capsule polishing. These fibrous plaques have become an integral part of the posterior capsule and therefore require surgical maneuvers such as posterior capsulorhexis or capsulectomy with vitrector. Moreover, the impact of even a mild degree of PCO on the performance of IOLs with extended depth of focus, trifocals, etc., could become bothersome to these patients. A good surgical technique leaving behind a “clean” capsular bag and inducing less postoperative inflammation would retard PCO formation. In addition to performing capsulotomy on the posterior capsule, YAG laser is also effective in treating moderate to severe degrees of anterior capsule fibrosis. Eyes with small capsulorhexis, uveitis, retinitis pigmentosa, and eyes with comorbidity are more likely to develop anterior capsule fibrosis. Early treatment with YAG laser would prevent the consequences of capsular fibrosis. As mentioned by the authors, YAG laser remains a very handy tool to deal with capsular opacification. Editors’ note: Dr. Vasavada disclosed no relevant financial information. Abhay Vasavada, MD Director, Raghudeep Eye Hospital, Ahmedabad, India icirc@abhayvasavada.com ASIA-PACIFIC PERSPECTIVES

CATARACT 12 EWAP SEPTEMBER 2023 T he cataract patient who has had prior refractive surgery requires extra considerations in terms of consultations/patient expectations, IOL selection, formulas, use of intraoperative technologies, and postoperative potential. Nicole Fram, MD, and Warren Hill, MD, provided their thoughts on the modern management of these cataract patients. Preoperative/consult period Dr. Fram said that the first step is to take a thorough history, determining whether the patient was of presbyopic age when they had laser vision correction, what type they received, and if monovision was a strategy used for presbyopia correction. “It is also important to review their current glasses prescription and ask direct questions such as, ‘Do you currently wear glasses when you look at your phone or computer, when reading and/ or driving at night?’ I will even go as far as asking to see the font on their phone to assess their level of presbyopia denial,” Dr. Fram said. “All of these questions will help you assess the proper timing of surgery and strategy necessary to achieve the highest patient satisfaction.” In her diagnostic workup, Dr. Fram includes manifest refraction, pachymetry, corneal topography with Placido imaging, wavefront or ray tracing technology (to determine the level of spherical aberrations and higher order aberrations originating from the cornea or the lens/vitreous), and a spectral-domain macular OCT. Dr. Fram said the type of refractive treatment (myopic or hyperopic) and centration of the ablation is also important for counseling. She finds Placido imaging useful to assess quality of vision potential to set expectations. In counseling, Dr. Fram said she uses her tablet to display Rendia Exam Mode and describe how the light travels in the eye. She explains to the patient how laser vision correction affects one of the important parameters used to calculate IOL power and the potential for inaccuracies. “I explain that although we are improving our ability to achieve emmetropia and hit the targeted outcome, there is still a chance they may need glasses postoperatively,” she said. Dr. Hill said that he takes preoperative measurements in a separate visit. “During this visit, I review these with the patient using a large, wall-mounted LED display screen connected to each of our instruments. The discussion concentrates on the topographic axial curvature map and an image simulation at various pupil sizes, with and without glasses; explaining to the patient how they will see after surgery is good, but showing them is far better,” Dr. Hill said. IOL selection IOL selection, Dr. Fram said, depends on patient expectations and type of ablation pattern. The post-myopic LASIK patient, for example, will usually have a positive or neutral spherical aberration profile, so an Contact information Fram: drfram@avceye.com Hill: hill@doctor-hill.com Making Practice Perfect for Post - refractive cataract patients by Liz Hillman Editorial Co - Director This article originally appeared under the title “Best practices for postrefractive cataract patients” in the July 2023 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Dr. Fram uses Rendia Exam Mode to explain to patients how light waves travel through the eye and how laser vision correction affects one of the parameters to calculate IOL power. Source: Nicole Fram, MD

CATARACT EWAP SEPTEMBER 2023 13 IOL with negative spherical aberration or neutral spherical is theoretically preferred, Dr. Fram said. Conversely, a patient with a hyperopic ablation, which Dr. Fram said is more challenging to obtain consistent keratometry measurements with, can cause negative or neutral spherical aberration. This, with a small pupil, can lead to a multifocal-like outcome. If the patient was previously happy with this ablation pattern without cataracts, Dr. Fram said she’ll often choose IOLs with zero spherical aberration. “The question often arises whether to choose an EDOF or diffractive multifocal/ trifocal technology in the post-corneal refractive population,” Dr. Fram continued. “There are many reports of excellent outcomes with this technology. In our experience, the ablation needs to be well centered with normal Placido imaging in order to have a satisfied patient. Some refer to the EDOF technology as ‘more forgiving’ than a multifocal or diffractive technology. However, if a surgeon is going to use this technology, they need to be prepared to remove the IOL because up to 19% of post- LASIK patients had to have an IOL exchange due to diffractive dysphotopsia, according to our research.” 1 This is where Dr. Fram finds the Light Adjustable Lens (LAL, RxSight) beneficial. “The LAL has been a huge boost for our practice in the post-LASIK/PRK patient population [because] the IOL targeting can be adjusted postoperatively and is less reliant on current IOL calculations,” she said. “This has become my preferred technique due to the postoperative adjustability, and the silicone IOL lends itself to a lower dysphotopsia profile in these already aberrated corneas.” While it’s still necessary with the LAL for the patient to have a well-centered ablation, normal Placido imaging, and a pupil that can dilate to at least 6.5 mm, Dr. Fram said the technology can achieve a customized mini - monovision without the need to disassociate the eyes more than 1.5 D. “Patients need to understand this is still a monovision strategy and they will need glasses for some tasks depending on the amount of anisometropia, such as driving at night and reading very small print. When we looked at the number of post-myopic LASIK ablation patients (n=35) achieving stable ±0.5 D at 1 year, it was 87%. Although this is a very small study group, the results are promising. Further, this has not been reported consistently in the literature in the post-laser vision correction population.” For Dr. Hill, the most important part of IOL selection with patients who have had prior refractive surgery is their aberration profile. “Those patients with significantly elevated higher order aberrations, such as coma and spherical aberration, are generally not multifocal IOL candidates,” Dr. Hill said. “This is reinforced by the image simulation, which typically demonstrates a loss of contrast.” IOL calculations Dr. Hill said the “go-to” IOL formula for those with prior refractive surgery is the Barrett True-K. If the patient is a toric candidate, and he said that this is uncommon, he’ll use the Barrett True-K Toric with the measured posterior corneal power. “For those patients who absolutely have to have an exact refractive outcome, the LAL is used,” he said. Dr. Fram said that many patients with prior refractive surgery expect to have similar refractive results after cataract surgery. However, their modified anterior corneal curvature isn’t accurate with traditional formulae that are based on assumptive keratometry principles. Dr. Fram cited research that has shown previous formulas developed for post-laser vision correction eyes, relying on historical keratometry, were within ±0.50 D of target less than 60% of the time. These, she noted, were eliminated from the ASCRS calculator. When post-laser vision correction ablation data are available, the Masket Regression formula achieves 85% within ±0.5 D and 95% ±1 D of target. 2 Newer formulae that don’t require historical data and intraoperative tools have further improved outcomes for these patients, Dr. Fram said. “Abulafia et al. reviewed the Barret True-K formula outcomes and found the Barrett True-K was comparable to results of the ASCRS calculator with a median absolute error of 0.33 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. What’s one thing you think surgeons should be doing with post-refractive patients who are cataract surgery candidates that many aren’t doing already? Dr. Fram: Understand the advancements in formulae, try to not leave the consenting process to a surgical counselor alone, and be prepared for an IOL exchange (particularly if using diffractive technology and/or if you do not have access to the LAL). Dr. Hill: Take all the time necessary to explain the limitations involved in the process. Essential items are: 1) This is not routine surgery for which all options are possible; 2) the calculation accuracy is less than for regular cataract surgery; and 3) the reduced contrast from elevated higher order aberrations will persist, especially at larger pupil sizes. Use image simulation to demonstrate what the postoperative vision will be. continued on page 15

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CATARACT EWAP SEPTEMBER 2023 15 D. 3 However, only 67.2% and 94.8% of eyes were within ±0.50 D and ±1.0 D from the target refraction, respectively,” Dr. Fram said. “Haigis reviewed 187 eyes and found that using the Haigis-L formula, the percentages of correct refraction predictions were within ±1.00 and ±0.50 D in 84.0%, and 61.0%, respectively. 4 “Most recently, Lawless et al. reported that using the Barrett True-K TK resulted in 75% within ±0.5 D versus 45% within ±0.5 D using the ASCRS calculator and standard keratometry. 5 Similarly, Yeo et al. found that EVO TK, Barrett True-K TK, and Haigis TK achieved 68%–64% within ±0.50 D. 6 Lastly, Wang et al. found that the performance of the combination of Haigis and TK in refractive prediction was comparable with Haigis-L and Barrett True-K in eyes with previous corneal refractive surgery,” 7 Dr. Fram said. Dr. Fram continued that more recent literature has shown the Haigis-L, 8 Barrett True-K TK formula, 5 ORA System (Alcon) intraoperative aberrometry nomograms, 9 and ASCRS calculator mean can achieve emmetropia up to 74%–76%. Intraoperative stage When in surgery, Dr. Fram said she’ll look at the ASCRS calculator average, Barrett True-K TK, using IOLMaster 700 (Carl Zeiss Meditec), and will use intraoperative aberrometry. “Of note, if there is anterior corneal astigmatism measured, I will look at the total K on the IOLMaster 700 to confirm magnitude and axis, what the patient was wearing in their glasses and axis, as well as use intraoperative aberrometry to look at the total aphakic refraction rather than simply the anterior measured astigmatism,” she said. She added that the Barrett True-K Toric is valuable if not using the LAL technology. If she’s using an LAL, she said she’ll pick the first plus on the Barrett True-K TK for the dominant eye and –0.75 D for the non-dominant eye. “I will add in the myopic correction to allow for an ‘EDOF effect’ by changing the spherical aberration of the adjusted IOL,” she said. Dr. Hill said his surgery is not different for patients with prior LASIK, PRK, or ALK. If the patient had RK and the incisions are too closely spaced, he will use a scleral tunnel. Dr. Hill said that intraoperative aberrometry would not improve outcomes, especially in the case of prior RK. Postop What if an enhancement is needed postop? Dr. Hill said this is rare, but if there is a significant refractive miss, IOL exchange is his preference. He said that the LAL “dramatically reduces this possibility,” but he noted, “it must be understood by everyone involved that these eyes do change over time.” Dr. Fram said if ablation is being considered, it’s important to see if the cornea can withstand another such a treatment. “Typically, even the monovision patients are consented that they may need spectacle correction for some activities such as driving at night or reading very small print. If there is a hyperopic outcome, the surgeon should be prepared to perform an IOL exchange,” she said. EWAP References 1. Alsetri H, et al. Diffractive optic intraocular lens exchange: indications and outcomes. J Cataract Refract Surg. 2022;48:673–678. 2. Fram NR, et al. Comparison of intraoperative aberrometry, OCT-based IOL formula, Haigis-L, and Masket formulae for IOL power calculation after laser vision correction. Ophthalmology. 2015;122:1096 –1101. 3. Abulafia A, et al. Accuracy of the Barrett True-K formula for intraocular lens power prediction after laser in situ keratomileusis or photorefractive keratectomy for myopia. J Cataract Refract Surg. 2016;42:363–369. 4. Haigis W. Intraocular lens calculation after refractive surgery for myopia: Haigis - L formula. J Cataract Refract Surg. 2008;34:1658 –1663. 5. Lawless M, et al. Total keratometry in intraocular lens power calculations in eyes with previous laser refractive surgery. Clin Exp Ophthalmol. 2020;48:749 –756. 6. Yeo TK, et al. Accuracy of intraocular lens formulas using total keratometry in eyes with previous myopic laser refractive surgery. Eye (Lond). 2021;35:1705 – 1711. 7. Wang L, et al. Evaluation of total keratometry and its accuracy for intraocular lens power calculation in eyes after corneal refractive surgery. J Cataract Refract Surg. 2019;45:1416 –1421. 8. Lanza M, et al. Accuracy of formulas for intraocular lens power calculation after myopic refractive surgery. J Refract Surg. 2022;38:443 – 449. 9. Refractive prediction accuracy using intraoperative aberrometry versus Barrett True-K formula in post-corneal refractive surgery eyes. Presentation at the 2021 American Academy of Ophthalmology Meeting, New Orleans, Louisiana. Editors’ note: Dr. Fram practices at Advanced Vision Care, Los Angeles, California, and has interests with Johnson & Johnson Vision, Alcon, Bausch + Lomb, RxSight, and Carl Zeiss Meditec. Dr. Hill practices at East Valley Ophthalmology, Mesa, Arizona, and declared no relevant financial interests. Making...Post-refractive - from page 13

CATARACT 16 EWAP SEPTEMBER 2023 T here are many motives and methods for IOL exchange. While a rare need, the physicians who spoke with EyeWorld said it’s important to be familiar with the indications for exchange, removal techniques, and considerations for IOL replacement. “Thankfully, the need to perform an IOL exchange is relatively uncommon in modern ophthalmology,” said Samantha Schockman, MD. Morgan Micheletti, MD, remembers IOL exchanges being portrayed as “a scary, complex, and challenging surgery” when he was a medical student. While these cases aren’t routine, he said that ophthalmologists are now more comfortable with the surgery. Joshua Teichman, MD, said the decision to exchange is a joint one between the surgeon and patient. “A surgeon who performs more IOL exchanges will have a low complication rate and likely offer this earlier than a surgeon who does not,” Dr. Teichman said. “It is important that those who implant IOLs more prone to dissatisfaction be comfortable with IOL exchange. When a patient is unhappy from something that is clearly attributable to the IOL and exchange has a reasonable chance of improving this, I think an exchange is warranted. It is important that other issues be ruled out first. If patients are unhappy with presbyopia - correcting IOLs immediately postoperatively, one can generally assume that this is not from posterior capsule opacification, and a YAG capsulotomy should be avoided. IOL exchange in the presence of an open posterior capsule increases the risk and may be surgically more challenging. One should be prepared to Contact information Micheletti: morgan.micheletti@gmail.com Schockman: sschockman@cvphealth.com Teichman: josh.teichman@gmail.com Making Practice Perfect for IOL exchange by Liz Hillman Editorial Co - Director perform a vitrectomy in these cases, and if the capsular bag integrity is compromised, be prepared with a 3-piece IOL for sulcus placement and/or flanged double needle intrascleral haptic fixation (Yamane).” Why exchange and when According to the physicians, there are several reasons for IOL exchange: refractive miss, dysphotopsias, intolerance to presbyopia - correcting designs, dislocation/subluxation, IOL defects/damage/opacification, and secondary issues (e.g., corneal edema from AC IOLs, UGH syndrome, etc.). “If you know it’s a miss, and you know there is stability, and you know it’s not an unusual situation like post-RK, but for whatever reason you’ve had a refractive miss, you can exchange relatively early on,” Dr. Micheletti said. “Relatively early I would say is within a month. If they’re not improving and they have a documented refractive error that’s large, I would go back in pretty quickly.” If the patient is off by less than a diopter, the patient is a good candidate, and it isn’t a rotational issue with a toric lens, Dr. Micheletti added that he’d consider a LASIK enhancement instead of intraocular surgery due to the risks. Dr. Schockman said when there is a mechanical or anatomical issue causing complications, the decision to proceed with an IOL exchange is relatively straightforward. “It can be less clear when an IOL This article originally appeared under the title “IOL exchange 101” in the July 2023 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. IOL cut in half in anterior chamber. Source: Joshua Teichman, MD, MPH

CATARACT EWAP SEPTEMBER 2023 17 exchange is warranted when the patient has visual complaints in an otherwise healthy eye,” she said. “When the patient is unhappy with their vision after cataract surgery, the surgeon should first make sure the correct IOL was placed, the IOL is in good position, and the eye is otherwise in good health,” Dr. Schockman said. “It is advisable to repeat IOL measurements for accuracy. Any other cause for the patient’s visual complaints should be ruled out. If there is dry eye, the ocular surface should be optimized. In the case of multifocal IOLs, the surgeon should allow adequate time for neuroadaptation to occur. Once a stable refraction has been demonstrated, laser vision correction can be considered in the case of a refractive miss. The surgeon should try optimizing the patient’s vision prior to deciding on an IOL exchange. If the patient continues to have problematic symptoms despite clinical optimization, a detailed discussion is warranted to weigh the benefits and risks of IOL exchange.” Dr. Teichman said if an exchange is being considered for incorrect IOL power or toricity, he’ll proceed once a stable refraction can be obtained. If the exchange is due to intolerance of a presbyopia - correcting IOL, some consider waiting months for neuroadaptation. Dr. Micheletti said if a patient is extremely bothered by severe dysphotopsias due to a diffractive IOL from the day of implantation, “you likely need to intervene sooner rather than later.” “I do try to go back in pretty quickly, within the first 2–3 months,” he said, noting that sometimes it means switching up IOL technology. He noted that the patient must understand what they might be giving up if they opt to exchange an IOL that they’re not entirely happy with. “You have to find out what exactly is bothering the patient and, in the case of a multifocal, if they’re willing to give up that near vision that they’re getting,” Dr. Micheletti said. “Some of my patients think about it and say, ‘I’m happy with my near vision, I don’t want to go back to glasses, I can handle this.’ That’s a very different conversation from the patient who says, ‘I can’t live like this, I’m miserable.’” How to exchange Focusing on in - the - bag IOL exchange, Dr. Teichman shared his usual process. “If the previous surgery was less than 3 months prior, I generally reopen the wound with a Sinskey hook,” he said. “If later, I will create a new wound, making sure it will not connect to the previous wound, which can occasionally reopen creating a very large unstable wound. I favor a slightly larger incision for IOL removal. The endothelium should be protected with dispersive viscoelastic and space created with a cohesive OVD (using the soft shell technique of Steve Arshinoff, MD). “It is important not to fill the anterior chamber completely as one will require additional OVD to free the IOL in the next steps,” he continued. “Next, ideally at the haptic-optic junction, dispersive OVD is injected just under the anterior capsule to begin the separation of the anterior and posterior capsule to open the bag. This can be done with a 30-gauge needle bevel down or a flat LASIK cannula. Once the separation has begun, the usual OVD cannula can be used to propagate this. This step is a combination of viscodissection and gentle manual dissection at times. The goal is to open the capsule 360 degrees. The location of the densest adhesions varies by the haptic shape and may be the proximal or distal portion. Once the IOL is partially freed, OVD is inserted posteriorly to protect the posterior capsule. Once the IOL is completely freed, it is brought into the anterior chamber, and with good protection of the endothelium and posterior capsule, the IOL is cut using intraocular IOL cutters. This is best performed with the second hand holding the IOL using micro-instrumentation. I generally completely bisect the IOL, but other techniques exist, including creating a Pac-Man or twisting maneuvers. Some surgeons will insert the second IOL posterior to the first, prior to cutting the first, to protect the capsular bag.” Dr. Schockman said having a plan and a backup plan (or two) prior to removal is important. “To remove an IOL from within the capsular bag, it’s critical to ensure viscoelastic material is used to completely free the haptics. There can be fibrosis and scarring around the haptics, and manipulation of the haptics before they are completely freed can result in zonular dehiscence or capsular rupture,” she said. “Gentle dissection can be performed, but attempts to rotate the IOL before the haptics are free should be avoided. In some instances, the haptics cannot be freed, and the surgeon may amputate the haptics and remove the optic only. A new IOL can still be placed in the bag 90 degrees away, if a toric IOL is not required.” Dr. Micheletti and Dr. Teichman also shared this advice about leaving a haptic, if it cannot be easily freed. Dr. Micheletti noted that sometimes cutting at the haptic gives the surgeon more flexibility that could lead to its removal during the case. Depending on the IOL material, the first IOL can be folded, cut, or removed whole, Dr. Schockman said, also mentioning the Pac- Man technique. Both Dr. Schockman and Dr. Micheletti discussed inserting the second IOL posterior to the original to act as a scaffold, protecting the capsule. Dr. Schockman also gave the tip of using enough viscoelastic to protect the corneal endothelium while

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