eyeworldap.apacrs.org The Asia-Pacific Association of Cataract and Refractive Surgeons ASIA-PACIFIC Vol. 20 No. 1 March 2024 www.eyeworldap.apacrs.org
2 EWAP MARCH 2024 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) FEMTOSECOND LASER-ASSISTED CATARACT SURGERY Current Perspectives and Outcomes 07:30 – 08.45hrs (S5) IIIC LECTURES The Perfect Save! (S6) BITS & BYTES FOR THE FUTURE Digital & AI in Ophthalmology (S7) CHALLENGE OF CATARACT REFRACTIVE SURGERY IN COMPLEX CASES FREE PAPERS 09:00 – 10:30hrs OPENING CEREMONY & APACRS LIM LECTURE 07:45 – 09:15hrs (S13) CATARACTS & CONFUCIUS Rules to Success (S14) PANDERING TO PRESBYOPIA (S15) PATIENT SELECTION AND EXPECTATION MANAGEMENT FOR REFRACTIVE PROCEDURES 09:30 – 12:25hrs (S16) LIVE SURGERY/SURGICAL VIDEO SYMPOSIA FREE PAPERS 10:30 – 11:00hrs Tea Break 11:00 – 12:30hrs MASTERCLASSES (S2) BEYOND 20/20 Exploring Innovations in Refractive Surgery 11:00 – 12:30hrs (S8) PATHWAYS TO PRECISION & PERFECTION Combined Symposium of the Cataract & Refractive Societies (CSCRS) – APACRS, ASCRS & ESCRS FREE PAPERS 12:45 – 13:45hrs INDUSTRY LUNCH SYMPOSIA 14:00 – 15:30hrs MASTERCLASSES (S3) CHOOSING THE RIGHT LENS An Introduction to IOL Selection 14:00 – 15:30hrs (S9) A BREAK IN THE CLOUDS Cataract & Complications (S10) YIN & YANG Controversies in Refractive Surgery (S11) REFRACTIVE SURGERY FOR THE AGING EYE Approaches and Considerations FREE PAPERS 14:00 – 15:30hrs (S17) KNOW YOURSELF, KNOW YOUR ENEMY Challenging Cases (S18) GREEN SHOOTS What’s New in IOLs? (S19) CLEAR VISION AHEAD The strategies for special cataract patients FREE PAPERS 15:30 – 16:00hrs Tea Break 16:00 – 17:30hrs MASTERCLASSES (S4) REFRACTIVE ERRORS DEMYSTIFIED Myopia, Hyperopia, Astigmatism, and Presbyopia 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 Visit www.apacrs2024.org for regular updates!
EWAP MARCH 2024 3 EDITORIAL EyeWorld Asia-Pacific • March 2024 • Vol. 20 No. 1 Graham Barrett Chief Medical Editor EyeWorld Asia-Pacific • China • Korea • India T he Greatest Teacher” evokes thoughts of mentors we have had in our pre- and postgraduate training who have had such a dramatic influence on highlights and careers. Nevertheless, I would suggest the “Greatest Teacher” also applies to our patients and clinical experience over many years. This is particularly the case when discussing considerations for proceeding with cataract surgery. Several experts provide their thoughts and bring to my mind how I counsel my patients, in that the decision to proceed with cataract surgery typically does not rely on the appearance of the cataract or what they read on the chart but rather the difficulty they are experiencing with the clarity of their vision. Once they have reached the stage where the quality of their vision is unsatisfactory for near or distance then proceeding with surgery is advisable as the symptoms will only progress. Naturally, this is accompanied by a discussion on the risks of surgery as well as letting them know that in addition cataract surgery does provide an opportunity to reduce dependence on spectacles. There are of course exceptions. Sometimes, the density or maturity of the cataract is such that deferring surgery may lead to a greater risk of complications. A similar situation arises when there has been recent angle closure, the risk is considered likely, or a previous attack has occurred where removal of the lens is advisable. On the other end of the spectrum, be wary of patients with visual complaints where the density of the cataract does not appear compatible with the symptoms. A recent patient was referred for surgery in his 70s with corrected acuity of 6/6. There was early nuclear sclerosis but his description of visual difficulty was vague and did not match the density of cataract. I performed visual fields and found a bitemporal loss, which was confirmed on MRI to be a pituitary tumor. It is always wise to caution that the prediction of outcome is not 100% accurate despite the best methods of measurement and they will still require reading glasses unless a presbyopic strategy such as extended depth of focus or modest monovision is considered. The old adage of “under-promising and overdelivering” is certainly applicable. Many years after graduating, the decisions we make as ophthalmologists tend to be based on clinical training and the textbooks we have read. With experience however we increasingly consider the patient we have cared for over the years and the lessons we have learned from them—the Greatest Teacher. “
4 EWAP MARCH 2024 30 MAY - 01 JUNE 2024 CHENGDU, CHINA MASTERCLASSES Thursday, 30 May 2024 Visit www.apacrs2024.org for regular updates! TIME INTERCONTINENTAL BALLROOM JIN NIU ROOM QING YANG ROOM 09:00 – 10:30hrs MASTERCLASS (MC1) MASTERING IOL FIXATION Course Directors: CHEE Soon Phaik & XU Wen MASTERCLASS (MC2) MASTERING VITRECTOMY AND OCT FOR THE CATARACT SURGEON Course Directors: Thanapong SOMKIJRUNGROJ, Nikolle TAN & LU Yi MASTERCLASS (MC3) MASTERING MIGS FOR BEGINNERS - Tips and Tricks Course Directors: Chelvin SNG & WANG Kaijun TEA BREAK 11:00 – 12:30hrs MASTERCLASS (MC4) MASTERING CHOPPING & PRE-CHOPPING Course Directors: Ronald YEOH & GUO Haike MASTERCLASS (MC5) MASTERING CORNEAL ENDOTHELIAL TRANSPLANTATION Course Directors: Donald TAN & HONG Jing MASTERCLASS (MC6) MASTERING PHAKIC IOLS Course Directors: John CHANG & WANG Xiaoying INDUSTRY LUNCH SYMPOSIA 14:00 – 15:30hrs MASTERCLASS (MC7) MASTERING BIOMETRY Course Directors: FAM Han Bor & JIN Haiying MASTERCLASS (MC8) MASTERING REFRACTIVE SURGERY COMPLICATIONS Course Directors: Marcus ANG & HAN Wei MASTERCLASS (MC9) MASTERING ANTERIOR SEGMENT OCULAR TRAUMA Course Directors: Anshu ARUNDHATI & JIANG Yongxiang TEA BREAK 16:00 – 17:30hrs MASTERCLASS (MC10) MASTERING TORIC IOLS Course Directors: Tetsuro OSHIKA & SHENTU Xingchao MASTERCLASS (MC11) MASTERING PAEDIATRIC CATARACT SURGERY Course Directors: Vaishali VASAVADA & BAO Yongzhen MASTERCLASS (MC12) MASTERING PHACO FLUIDICS Course Directors: Pannet PANGPUTHIPONG & FAN Wei
EWAP MARCH 2024 5 CONTENTS SAILING THROUGH COMPLICATIONS CATARACT 08 Considerations for proceeding with cataract surgery by Ellen Stodola 11 Agitation in the OR by Liz Hillman 14 Learning from medical documentation errors by Liz Hillman 03 Editorial 21 Assessing IOL tilt and decentration by Ellen Stodola 24 Toric troubles: Postop rotation by Liz Hillman GLAUCOMA 33 Complications in cataract surgery with a functioning trabeculectomy by Ellen Stodola 36 Lessons from glaucoma training by Ellen Stodola CORNEA 27 Addressing neurotrophic keratitis by Ellen Stodola 30 Perspectives on ocular allergy and allergic conjunctivitis by Liz Hillman REFRACTIVE 17 Expanding experience with the EVO ICL by Ellen Stodola NEWS & OPINION 39 Drug waste and how physicians can move the needle at their institutions by Jake Grodsky, MD, and David Palmer, MD 41 AI inroads in ophthalmology by Liz Hillman FEATURE The Greatest Teacher
6 EWAP MARCH 2024 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 and OCT for the Cataract Surgeon, MIGS for Beginners - Tips and Tricks, Chopping & Pre-Chopping, Corneal Endothelial Transplantation, 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 Dr Shin Yamane delivers the 2024 APACRS LIM Lecture titled The Tales of Flanging Technique. He will reveal everything about the flanging technique: How the flanging technique was developed; what other techniques exist besides the original flanged IOL fixation technique; and the problems with the flanging technique and how to overcome them. Not to be missed! 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 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 & AI in 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 Visit www.apacrs2024.org for regular updates!
EWAP MARCH 2024 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) 038/02/2024 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 Abhay Vasavada, MD Deputy Regional Editor S. Natarajan, 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 IMPORTANT DATES 18 March 2024 Deadline for 1st Tier Early Bird Registration Rates 18 April 2024 Deadline for 2nd Tier Early Bird Registration Rates Online registration closes on Saturday, 18 May 2024 to facilitate preparations for the in-person meeting. Onsite registration commences at 14:00hrs, Wednesday, 29 May 2024 at West Tower, Lobby, 1F Holiday Inn Century City No. 208 West Tower, Century City Blvd, Gaoxin District, Chengdu, 51 610041 China apacrs2024.org
CATARACT 8 EWAP MARCH 2024 Before deciding to move forward with cataract surgery, there are a variety of factors that surgeons must consider. Several physicians discussed the timing of the surgery and how they counsel patients about this. Mitra Nejad, MD, said it’s less about how advanced the cataract is on the exam and more about the patient’s description of how they are bothered by their vision. Dr. Nejad has a mix of patients, including referrals from colleagues, so she often sees more visually significant cataracts that are ready for surgery. “On the other hand, I’ll get some self-referrals or primary care physician referrals for evaluation of cataract, and I often schedule those alongside an optometrist who I work closely with, in case all they need is an updated glasses prescription,” she said. When getting referrals from retina colleagues, Dr. Nejad said these might need to be operated on more quickly because the cataract is impairing the Contact information Kandavel: valleyeyedoctor@gmail.com Nejad: mnejad@mednet.ucla.edu Rai: amandeepraimd@gmail.com Considerations for proceeding with cataract surgery by Ellen Stodola Editorial Co - Director physician’s ability to provide treatment for the retina pathology. Dr. Nejad said it’s rare that the cataract surgery must happen urgently. However, she noted that some patients come in having failed a driving test, and she wants to address these patients as soon as possible to get them back to functional status. “Otherwise, I usually tell the patient, ‘The cataract is significant, I think you should consider surgery, but the good news is there’s nothing urgent about it, and you can schedule the surgery at your convenience.’” If the cataract is mild and the patient isn’t eager to do surgery, Dr. Nejad will ask the patient to come back in a year. If the cataract is dense and the patient isn’t eager to have surgery, she’ll have them return sooner. Dr. Nejad has noticed that because patients are hearing good things from family and friends about refractive cataract surgery, this decreases their overall anxiety about eye surgery. Dr. Nejad noted that she has seen a wave of worse pathology with the COVID-19 pandemic because patients have gotten used to a lifestyle with less driving and more time at home. Patients weren’t coming in for elective procedures and weren’t noticing visual impairment as much until they had to go out Dr. Kandavel tries to establish a strong personal connection with patients over years of appointments or even in one meaningful consultation. “Trust is the key to patients following your surgical recommendations,” he said. Source: Rom Kandavel, MD This article originally appeared in the December 2023 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp.
CATARACT EWAP MARCH 2024 9 and drive at night again. “For a while, I was seeing a lot of advanced cataracts, a lot of people who waited longer than they should have,” she said. Amandeep Rai, MD, has also found that coming out of the pandemic, there has been a noticeable trend toward patients presenting with more advanced cataracts. “The delayed access has certainly resulted in more patients presenting with advanced, visually significant cataracts in the last 2 years,” he said. “However, I do see a fair number of patients with milder symptoms who are referred from their optometrist for a surgical consult,” he said. “If they are minimally symptomatic, I will often ask them to follow up with the optometrist until the cataract becomes more advanced.” The decision to proceed with cataract surgery is jointly made by the patient and the ophthalmologist, Dr. Rai said. While cataract surgery is safe and can have a profound impact on a patient’s quality of life, it is ultimately an elective surgery. With more advanced cataracts, the patient has already been symptomatic for some time and arrives at the consultation ready to proceed with surgery. “With respect to allowing the cataract to become more visually significant, the Lens Opacities Classification System III (LOCS III) is a great scale. With the most common subtypes of cataracts, a lower LOCS III grade cataract can be observed if the patient is tolerating the lens changes, while a higher-grade cataract is ready for surgery,” he said. “If we elect to observe a cataract, I ask the patient to monitor their symptoms and return once they think their lifestyle is impacted. Typical early complaints include difficulty with night driving or frequently updating their spectacles due to shifting refraction and a drop in their best corrected visual acuity.” Rom Kandavel, MD, thinks that as a patient, a good question to ask when considering cataract surgery is, “With my best pair of glasses, what vision problem do I wish to solve through cataract surgery?” As a surgeon, you may want to ask, “Is the vision limiting the patient’s quality of life or their ability to perform daily activities the way they want to be perform?” If you can’t find the answer to those questions, you probably shouldn’t be operating on that patient, he said. “That is the premise of what I look for in a conversation. It’s not a discovery when they need surgery. The vision is already impacting the patient’s quality of life. The need to improve the vision should be obvious to the surgeon and to the patient.” You never want to be in a position where you’re telling the patient that they have a problem that they are unaware of. He added, “In the rare circumstance that a patient has a problem after surgery, like glaucoma or retinal detachment, the patient should look back and know they made a clear self-driven decision to improve their vision through surgery. “Patients will commonly know they are ready for surgery, but they’ll still ask me, ‘Do I need this surgery?’” It’s not because they’re not sure, but Dr. Kandavel said they want reassurance in order to move forward with their decision. He will be supportive and positive. “I never do surgery on someone who I don’t think it will help significantly.” He also said that as surgeries become more routinely successful, physicians may become less mindful of the potential complications of a procedure. Operating on borderline cases can be less successful. “A good result, when evaluated in the context of moderate preoperative vision impairment, becomes unacceptable with a symptom such as mild halo after surgery. “I always tell residents that the patient’s satisfaction with your surgery is not always linked to the result but to the process that you establish with the patient, earning trust over years of appointments,” he said. “If you build that trust, not only do you have a more fulfilling career, but you also have a more successful one.” When patients trust you, they are much more likely to put their faith in your recommendations because of that earned relationship. Dr. Kandavel said there are some reasons to operate sooner rather than later. One potential issue is cases with narrow angles. “In hyperopic patients who fail to have an angle improvement with laser iridotomy, cataract surgery can become medically indicated,” 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. LESSONS LEARNED Rosa Braga-Mele, MD, EyeWorld Cataract Editorial Board member: I have found that when dealing with complaints of quality of vision from MFIOL patients, it is important to listen but also show them what their near vision would be like without the MFIOL. I put up –2.50 trial lenses in front of their eyes while having them hold a Jaeger near card. Once they see what their up-close vision would have been like with a monofocal IOL, most will stop complaining about little issues. Also always let your patients know it can take up to 3–6 months for foreign body sensation to go away and neuroadaptation to take place with their new lenses.
CATARACT 10 EWAP MARCH 2024 he said. In a discussion of factors that could sway a surgeon or patient to have surgery done sooner, one of the most common is the desire of the patient to reduce spectacle dependence. He often counsels patients, “Don’t do cataract surgery just to eliminate glasses because I cannot ensure that 100% of the time.” However, there are some circumstances where less spectacle dependence can play a role. “If the patient has presbyopia and is a high hyperope or myope who has already undergone vitreous separation, you could consider the desire to reduce spectacle dependence because there is also a significant quality of life improvement in those circumstances.” Another example would be someone who is a long-time contact lens wearer with monovision. Those patients may not tolerate their monovision any longer, which can be unsettling. “If they desire to stay in functioning monovision and they no longer can, cataract surgery may be indicated,” he said. Patients with glaucoma who are on multiple drops and have trouble taking them consistently may be another case in which to operate earlier, when combined with MIGS procedures to improve compliance. Dr. Rai said patients may present with comorbid conditions that add complexity to their cataract surgery. Common ocular comorbidities include pseudoexfoliation syndrome, previous vitrectomy, and poorly dilating pupils that may predispose to intraoperative floppy iris syndrome. “We know these patients may be at increased risk for intraoperative complications, and allowing the cataract to become hypermature only serves to elevate the complexity of the surgery for the surgeon and the corresponding risk for the patient,” Dr. Rai said. “I have been referred patients who previously had complicated surgery elsewhere for their first eye, and their second eye was canceled and has subsequently progressed to a hypermature cataract,” Dr. Rai continued. “Understandably, these patients are concerned about proceeding with cataract surgery in their ‘good eye,’ but they have paradoxically increased the risk for complications by delaying surgery. Of course, when there is a surgical complication, the first priority is to rehabilitate that eye to its visual potential, which is often quite good. Once that is accomplished, the other eye should not be ignored, and the patient should be offered cataract surgery in a reasonable timeframe. A referral to a colleague can help reduce stress for both the patient and ophthalmologist. Another example is a patient who presents with a rapid onset white cataract in one eye and an early posterior subcapsular cataract in the other eye. I would proceed with removing both cataracts as soon as possible instead of allowing the mild posterior subcapsular cataract to rapidly progress into a more complicated surgical case.” When deciding when to move forward with cataract surgery, Dr. Kandavel said he will ask patients to clear their schedules for 3–4 weeks after surgery in case anything occurs in the postop period. “I also tell them on initial consultation that they won’t be able to go in the pool or in the water at the beach. I always tell them if they plan to go outside the continental U.S. to take that trip before they have surgery. I generally don’t recommend doing one eye, going on vacation, and coming back and doing the other,” he said. “I frequently will have a husband and wife come in for a simultaneous consultation, and I always tell them that only one person can have surgery at a time because they need someone to be the driver, and they may need someone to put in drops if that ends up being a problem.” If patients decide at the end of the consultation to postpone surgery, Dr. Kandavel said that he advises them that he will repeat testing and the dilated exam 90 days after the consultation. “Patients are highly educated about cataract surgery and their lens options even prior to their consultation with me,” Dr. Rai said. “They have consulted their friends and the internet to learn about their intraocular lens options, and many patients are seeing cataract surgery as an opportunity to improve their clarity and best corrected vision and their pre-existing refractive error. “Patients who have more advanced cataracts are very easy to please because the postoperative difference in best-corrected visual acuity is more appreciable. However, with improved IOLs and biometry, modern cataract surgery allows great predictability with respect to reducing refractive error. As a result, patients who have significant pre-existing refractive error also tend to be quite pleased following cataract surgery as they notice a large benefit in their uncorrected distance visual acuity and possibly a presbyopic benefit as well,” Dr. Rai said. EWAP Editors’ notes: Dr. Kandavel practices at Colvard-Kandavel Eye Center, Encino, California, and has interests with Alcon, Bausch + Lomb, Glaukos, and Tarsus. Dr. Nejad is Assistant Professor of Ophthalmology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, and declared no relevant financial interests. Dr. Rai is Residency Program Director, Department of Ophthalmology & Vision Sciences, University of Toronto, Toronto, Canada, and has interests with Alcon and Bausch Health.
CATARACT EWAP MARCH 2024 11 A nxiety is common among patients headed into the OR for cataract surgery, but when anxiety turns into agitation, it could mean a higher risk for intraoperative complications or a delay in surgery. “At least 10% [of patients] can become anxious or agitated. This can take many forms, from a patient shaking their leg to something more drastic such as suddenly moving their head,” said Shawn Lin, MD. Rosa Braga-Mele, MD, further differentiated. She also said she thinks anxiety occurs in 10 – 20% of cases, while 5% of patients experience some disinhibition and 1% reach true agitation. “It’s a spectrum,” Dr. Braga-Mele said. “Agitation itself is very rare. It’s a whole spectrum of anxiety, disinhibition, agitation.” The anxiety spectrum Anxiety is normal and experienced to some level by all patients who are fearful of the operation. Dr. Braga-Mele said Contact information Braga-Mele: rbragamele@rogers.com Lin: slin@jsei.ucla.edu Agitation in the OR by Liz Hillman Editorial Co - Director anxiousness can be controlled with more medications or verbal anesthesia (talking to the patient before and during the surgery about what to expect and what’s going on). Disinhibition is when the person is not entirely in control of their faculties, she continued, and can occur with too much medication, due to patient personalities or pre-existing conditions, or how they react to medication. Working with anesthesia, handholding, and gentle verbal anesthesia is helpful in these situations. Agitation occurs when the patient is out of control to a point where surgery needs to stop temporarily or be postponed entirely for patient safety. When a patient becomes truly agitated, Dr. Lin said it’s often too late for anesthesia to make efficient adjustments for the case. “The key is to recognize it early enough to come out of the eye before the real agitation occurs,” Dr. Braga-Mele said. “Deal with the agitation, talk to the patient before you go back into the eye. Don’t try to deal with agitation while you’re in the middle of doing phaco because they may move.” Preventative medicine Dr. Lin said he thinks the most important thing to alleviate anxiety and help avoid true Dr. Lin talks to a patient while administering proparacaine before cataract surgery. He likes to speak with patients outside the room to try to make them comfortable. Source: Shawn Lin, MD This article originally appeared in the December 2023 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp.
12 EWAP MARCH 2024 CATARACT agitation in the OR is prevention and setting expectations. “I talk to patients outside of the room, get them comfortable, get them to laugh, loosen them up a bit. I tell them it’s almost like a concert: There is a light show, music, and they’re going to have a couple of glasses of wine,” he said. “I try to set the expectation of what they’re going to experience in a positive light.” He said that expectation setting is especially important on the second eye. “I find that discomfort is about two to three times higher on the second eye,” he said. “They expect that everything is going to feel the same, but they essentially have perioperative amnesia due to the medications they received during the first surgery. I like to tell them that the second eye will feel like a completely different surgery, and they will likely perceive the whole thing as a brand new experience.” Dr. Lin said this is an area he is actively researching, seeking to figure out what actions by the surgeon, anesthesiologist, and support team might help patients be less anxious or agitated during the second eye surgery. “I’ve thought about giving patients a sheet of paper in the preoperative area when they arrive for their second eye surgery to let them know that the second eye will feel different than the first eye, to ensure they get the message in multiple ways,” he said. Dr. Lin and his team also send text messages and emails to patients prior to surgery, telling them what to expect. “We smother them with attention to let them know we care and are thinking of them. This can be helpful to alleviate some of their anxiety, and hopefully that leads to less agitation during the surgery,” he said. Dr. Braga-Mele said there are some patients who are more likely to become agitated in the OR. Older patients and those with any form of dementia or cognitive conditions are more likely to experience agitation under anesthesia. “Sometimes it’s better, if the patient is reasonable, to go with no sedation at all and use topical and verbal anesthesia. Keep them informed throughout the case so their anxiety lessens,” Dr. Braga-Mele said, adding that she talks throughout almost the entire case. She also said that she tapes around the patient’s forehead to the OR bed, with prior consent, which prevents movement, and in some cases, actually alleviates patient anxiety if they’re fearful they are going to move during the case. 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. Close calls Dr. Braga-Mele shared two cases where patients became significantly disinhibited or agitated. In one, 26 years ago when she was a resident, the patient sat straight up, swerving around the operating microscope, while Dr. Braga-Mele had a cystotome in the eye and was creating the capsulorhexis. Thankfully, they were able to carefully guide the patient back down. The case proceeded normally with no complications. “That’s when I started taping around the patient’s forehead to the OR bed,” she said, noting it’s with prior consent. She shared another case where the patient was severely claustrophobic under the drape. This was true agitation, and the case was ultimately aborted for a later date under general anesthesia. “The minute I put the drape on, even with conscious sedation, [the patient] screamed and fought and pushed, and I could not deal with it. She could not have the drape on,” Dr. Braga-Mele said of the one patient in her career of 20,000+ patients where she had to abort the case. What to do If a patient becomes significantly disinhibited or agitated to the point where surgery needs to pause, Dr. Braga-Mele said the surgeon needs to stay as calm as possible. “The more agitated you become, the more agitated the room becomes and your patient becomes, and your complication rate will go up,” she said. She said the key is to keep talking to the patient and being soothing, letting them know what’s going on. Dr. Braga-Mele also discussed how it’s important to not over sedate. Too much sedation can cause further memory issues in those with dementia, increase the likelihood of agitation/ disinhibition, and/or cause the patient to go into a deep sleep. “If I know my patient is asleep, I say to anesthesia, ‘Can you please hold their hand, they’re asleep.’ Then I stroke the patient on the forehead and say, ‘Wake up, you’re in surgery, we’re doing your eye surgery.’ Again, it’s that verbal anesthesia,” she said. “A lot of times I’ve had patients wake up completely oblivious to where they are if they are very sensitive to the anesthesia.” Dr. Lin reiterated that if the first eye was a challenge — the patient was anxious or agitated during the case—be prepared for a similar experience with the
CATARACT EWAP MARCH 2024 13 second eye, setting expectations beforehand, giving patients plenty of verbal anesthesia during the case, and working with the anesthesia team for the appropriate medications. “They’re always going to have some level of anxiety and sometimes agitation about the experience being different, so I think preparation is most important,” he said. EWAP Editors’ note: Dr. Braga-Mele is Professor of Ophthalmology, University of Toronto, Toronto, Canada. Dr. Lin is Assistant Professor of Cataract and Refractive Surgery, Associate Residency Program Director, and Medical Director, UCLA Stein Eye Center Calabasas, Los Angles, California. Neither declared any relevant financial interests. A s a team of cataract doctors in the ophthalmology department of a general hospital, we often have to face the agitation in the operating room from patients whose conditions fluctuate during the cataract surgeries. Usually, the anticipated agitation in the O.R. brings less worry. An unexpected agitation may make the surgical procedure difficult, terminate the surgery, even endanger the safety of patients. Fortunately, an unexpected agitation can be transformed into anticipated agitation by prior evaluation, adequate preparation, timely and accurate reaction to minimize possible harm. Common agitations in O.R. from patients include: 1. Psychological conditions: such as claustrophobia, fainting during acupuncture or with sight of bleeding, manic episodes, anxiety and stress causing breathlessness or hyperventilation, sudden increases in blood pressure or heart rates, and so on. 2. Systemic conditions: sudden increases in blood pressure, heart rates, blood glucose, body temperature; physical dysfunction such as kyphosis or spinal disorders; significant head or eyeball tremors. For psychological or systemic conditions, it is most important to ask for medical history in detail and seek for specialist help before surgery. An adequate education can relieve the patient’s anxiety. An enough sleep, reasonable diet and suitable clothing can reduce the fluctuation of heart rate, body temperature, blood pressure and glucose. All vital signs should be checked before patients transferring into O.R. For a high-risk patient, it is better to select a skilled surgeon, a surgical approach with less damage and shorter duration, and determine an appropriated anesthesia by the surgeon, anesthesiologist and patient together. For a local anesthesia patient, sedatives and oxygen can be used. Physical dysfunctional patient can be well equipped with protective gear and cushions. If the local anesthesia cannot help the surgery being completed safely, preparation in advance and timely switch for general anesthesia can help to complete the operation successfully. The better choice is to postpone the operation and control the patient’s condition when the patient is complicated with acute infection or other severe general condition that endangers the patient’s safety. 3. Eye conditions: including sudden aggravation in the previous condition, such as significant extension of lens dislocation at the supine position compared with sitting examination, sudden increase of intraocular pressure after mydriasis in a narrow-angle eye; occurrence of new signs, such as ocular bleeding, corneal opacity, new fundus lesions. It is very important to do: full ophthalmic examinations before surgery with mydriasis if permitted and/or with supine position if lens/IOL dislocated happened; systemic examinations including blood coagulation function and platelet counting; peri-operative medication such as IOPlowering drugs, NSAIDS, hemostatic drugs, antibiotics; a preoperative conversation containing of all possibility; recheck of important examination before a complicated cataract surgery such as slit-lamp, fundus examination, IOP, B-scan, UBM or AS-OCT if necessary; the selection of suitable anesthetics, mydriatics and antiseptics; full preparations of possible equipments, supplies and instruments; professional personnel supporting such as a retinal or corneal surgeon; a green channel for possible patient transport. Editors’ note: Dr. Xu disclosed no relevant financial interests. Wen Xu, MD Eye Center, 2nd Affiliated Hospital of Zhejiang University 88 Jiefang Road, Hangzhou, China xuwen2003@zju.edu.cn ASIA-PACIFIC PERSPECTIVES
CATARACT 14 EWAP MARCH 2024 Despite best efforts, medical documentation errors happen, both on paper charts and electronic files. The consequences of some of these errors can have ranging effects on patients and the practice. From a patient standpoint, Dagny Zhu, MD, and John Bartlett, MD, shared several ways that this could affect outcomes and patient satisfaction. Steve Christensen said, “Documentation errors have the potential of creating patient mistrust, inaccurate treatment plans, coding/billing errors, and lost revenue.” “I think, unfortunately, [medical documentation errors] are relatively common,” Dr. Bartlett said, adding, however, that “most of the time documentation errors don’t have any impact on medical care, which is good.” In electronic health records, Dr. Bartlett said he thinks some of the most common errors occur from using a copy forward function. “It’s easy in most medical record systems to take a previous note and duplicate it. … People will copy a note forward, and they don’t update things like new clinical findings or the plan, so you might see there is a note from several months after cataract surgery that states Mr. Jones is doing well 1 day after cataract surgery, even though he had surgery 3 months ago,” Dr. Bartlett said. Some EHRs allow for generation of stock phrases, commonly called “dot phrases” because you use a period to invoke it, Dr. Bartlett explained. “People have standard things. They will say we talked about the risks/benefits of surgery, patient agreed to proceed, that kind of stuff. I have seen one part of the chart say one thing and a different part of the chart say something else. For example, we had a surgeon who Contact information Bartlett: bartlett@jsei.ucla.edu Christensen: stephen.christensen@hsc.utah.edu Zhu: dagny.zhu@gmail.com Learning from medical documentation errors by Liz Hillman Editorial Co - Director had a surgery where they talked with the patient about setting certain focusing with cataract surgery. The patient thought they were going to have both eyes set for near for reading. They documented that clearly in one part of the chart, but they used a stock phrase for the part of the chart that was for the plan. When they selected the lens, typically we select a lens for distance focusing, and that’s what they did, and the patient ended up with a lens focused differently than what they expected because of a The copy forward button on many EHRs as seen here makes it easy to inadvertently propagate outdated or erroneous information in medical notes. Source: John Bartlett, MD This article originally appeared in the December 2023 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp.
CATARACT EWAP MARCH 2024 15 documentation error.” Coming from a paper chart perspective, Dr. Zhu said the most common error she sees is the wrong information in the wrong chart. “I think it still applies even for clinics that are all digital because there are some things that are not completely connected to your EHR. There are a lot of scans that you have to print out and scan into the EHR. That can be uploaded into the wrong patient record. That’s the most common error that I’ve seen,” she said. “Sometimes it’s a completely different patient, and sometimes it’s because the patient shares the same name, so you always have to verify the birthday as well.” Dr. Zhu said this has happened in her practice when technicians are printing out from devices one after another, and sometimes the whole stack of papers is scooped up and put into a chart. Sometimes, sandwiched in the middle are scans from another patient. “I’ve educated my staff to not blindly scoop up the whole stack from the printer. They should individually look through each paper as they’re putting it into the chart, verifying the name and birthday,” she said. Dr. Zhu and Dr. Bartlett have not experienced a negative patient outcome due to a chart error personally, though they have caught errors through safety checks before they could affect outcomes and have heard of such situations from other practices. Dr. Bartlett said that human errors can be counteracted before and during surgery with systems of safety, including multiple checks by multiple people. “I work with an optometrist. When we see patients, we generate our lens orders, so when we do our calculations and pick a lens for the patient, he and I do that separately, and we compare the results. If there is any discrepancy, we figure out why there is a difference so it’s very clear what they elected for and what we are selecting. Once you type it in the EHR, it looks like that’s the reality. Unless you have some other check on it, you could easily make an error,” Dr. Bartlett said. Dr. Zhu said with ICLs, she makes sure to triple check that she’s ordering a lens with the correct axis because in the clinic, minus is used for cylinder during refractions, but the ICL needs to be converted to plus. She checks the ICL power when it is delivered to her practice before the patient is even scheduled and again on the day of surgery. It is very easy to mistakenly flip the plus/ minus sign on the astigmatism, and the patient could end up with double the amount of astigmatism they started with. 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. Pro for paper Dr. Zhu said she likes having everything in one place and being able to spend more time “face time” with the patient rather than on a computer. “I can review a chart and see the OCT, topography, biometry simultaneously. It’s also easy for me to handwrite notes in the chart to do calculations or highlight important findings when making my final IOL selection. It’s a little cumbersome when everything is electronic and you have to open different windows to do those same evaluations,” she said. Pro for digital While EHRs are, to some degree, “universally hated” among ophthalmologists, Dr. Bartlett said, enhanced communications facilitated by the electronic record is a plus. “There have been times in the past when I’ve gotten paper records and I can’t make out anything on it, so it’s zero information,” he said. “I think there is a value in being able to better communicate among physicians, to communicate with patients, and that leads to better patient care.” The same holds true for LASIK. It is important to verify that the refraction that is programmed into the laser matches the final refraction obtained on surgery day. “As a safeguard, I double check to make sure that the final refraction written in the chart is consistent with a recent refraction that was obtained at a separate preoperative visit. I then confirm once more that the numbers in the machine match the numbers in the chart with my laser surgical technician just before hitting the pedal,” she said. While these safeguards and surgical timeouts are not built into the EHR, Dr. Bartlett said EHRs do have some safety measures. For example, if a patient has listed an allergy and a doctor tries to order a medication they’re allergic to, the system would flag it. It also flags dosages that might be considered unsafe. From a business standpoint, medical documentation errors can be costly, not only in terms of OR resources, if a patient needs to be brought in for an additional procedure, but also in terms of insurance denials and the staff time needed to correct these issues and resubmit. Mr. Christensen gave an example. He said the Moran Eye Center recently underwent a “Target, Probe, and Educate” audit for cataract surgery. The findings included documentation omissions: “Per LCD L37027, documentation must include an attestation supported by documented symptoms and continued on page 20
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REFRACTIVE EWAP MARCH 2024 17 Contact information Hura: arjan.hura@gmail.com Lin: amylin78@gmail.com Parkhurst: gparkhurst@parkhurstnuvision.com Many surgeons have now gained experience with the EVO ICL (STAAR Surgical), which was FDA approved in April 2022. Several spoke to EyeWorld about what they’ve learned from using it in practice. Many physicians were using ICLs as a resource prior to the EVO ICL’s approval. Gregory Parkhurst, MD, has been a long-time ICL user, so he’s familiar with the platform. “Using the ICL as an important part of our refractive surgery offerings isn’t a new thing for Expanding experience with the EVO ICL by Ellen Stodola Editorial Co - Director us,” he said. “But when I speak to colleagues and peers, a lot are starting to try the ICL again now that the EVO ICL has been approved. Maybe they tried it years ago and stopped, and now they’re taking a second look. In our case, it’s the next modification of a platform that we’ve been using all this time.” While Dr. Parkhurst didn’t notice any major changes when the EVO ICL got approved, he did say that he was surprised at how much growth his practice has seen in ICL use since the approval. “I expected we might see a few more patients who qualified for it than who had qualified before, but I didn’t expect it to have the dramatic impact that we’ve seen,” he said. “More patients are asking about it, more are getting referred for it,” he said, adding that efficiencies on the operational side are also making it easier to get a patient through the process. Arjan Hura, MD, is a refractive surgeon at the Maloney-Shamie Vision Institute and said that he utilizes the EVO ICL on an almost weekly basis, and like Dr. Parkhurst, his practice has seen a dramatic increase in volume since the approval of the EVO ICL. Similar to other refractive surgeons, prior to the FDA approval, he was routinely implanting ICLs with his first experience in his refractive surgery fellowship in Cleveland, Ohio. Amy Lin, MD, said she has also used ICLs for years. “I didn’t change anything that I was doing as far as marketing more because I was already doing ICLs,” she said. “But I did find that because of the launch of the EVO ICL, there was more press about it, so I had more patients coming in asking about it.” Dr. Lin thinks the EVO ICL is a great option for high myopes and those with moderate myopia who are not candidates for LASIK or PRK due to thin corneas. “It’s great to be able to offer something for those patients instead of telling them This article originally appeared in the December 2023 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Dr. Hura performs ICL surgery using a 3D heads-up visualization display in the OR. Source: Arjan Hura, MD
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