EyeWorld India September 2016 Issue

3 EWAP September 2016 Dear Friends H ealthy controversy is a positive step in ensuring progress; it compels ophthalmologists to critically assess and refine their performance, enables innovators to come up with new ideas and stimulate research to circumvent any controversial approach that may currently exist. As ophthalmic science continues to progress, a multitude of diagnostic and treatment options now exist. Each may work in a given setting, and the choice rests with the surgeon depending on several factors such as novelty, familiarity, availability, scientific basis, and, lastly, cost. Controversy inevitably arises as to the “best” intervention available. This issue discusses several such “Controversies”. The use of intracameral antibiotics is steadily rising among cataract surgeons worldwide. It has the definite promise of reducing the risk of endophthalmitis1, yet there are several concerns that need to be addressed. Most intracameral antibiotics are not available as a commercial preparation, and issues related to pharmacy compounding and dilution errors surface from time to time. Intracameral cefuroxime is not available as a commercial preparation, except in a few countries. Meanwhile, the emergence of hemorrhagic occlusive retinal vasculitis (HORV), a visually devastating complication, raises serious questions on the safety of intracameral vancomycin. Moxifloxacin, a fourth generation fluoroquinolone, appears to be safe and effective so far. Personally, I have been using intracameral antibiotics for a long time, and have shifted from vancomycin to intracameral moxifloxacin for the last 9 years. The use of intracameral antibiotics will certainly be adopted by many more, but we hope that we can get safer, more efficacious, and easier-to-use preparations in the future. Immediately sequential bilateral cataract surgery has always been a matter of great controversy. Proponents of this approach cite its convenience and cost-effectivity, which may be true for some Western countries but may not be relevant to other parts of the world. Endophthalmitis remains a major safety concern and, in many parts of the world, we are still striving to achieve consistency in meeting target refraction and visual outcomes. It seems logical to assess the technical, functional, and refractive outcome in one eye to give us a chance to modify the surgical plan/technique for the other eye. Having said that, there are a few situations such as those who need general anesthesia or have high-risk systemic features in which immediate sequential bilateral cataract surgery certainly has a role. Nevertheless, for the population at large, delaying the second eye surgery at least by a few weeks seems to be the preference. Astigmatism correction at the time of surgery is becoming an integral part of cataract management. Toric IOLs have been a game changer of sorts here. Compared to other options such as LRIs, incisional methods, and laser refractive surgery, they seem to offer more predictable and precise outcomes. Moreover, it is a part of routine cataract surgery and does not involve learning additional skills or instrumentation for the surgeon. Finally, the frontier of refractive surgery is an exciting, fast progressing one. Modern-era LASIK has become one of the safest and most effective eye surgeries. And yet, there is a long way to go in terms of enhancing visual quality and reducing risks of side effects such as dry eye and ectasia. Newer treatment paradigms such as topography-guided procedures bring the hope of offering better visual qualities to a wider group of patients, including those with irregular corneas. At the same time, ReLex SMILE promises to be the next procedure on the horizon. It has a theoretical benefit of better preserving the biomechanical strength of the cornea and potentially reducing side effects such as dry eye. However, it also has its own set of limitations, and we await more systematic scientific studies for this procedure. Until then, LASIK remains the most widely sought after option for refractive surgeons. These are exciting times for clinicians and scientists. In the end, it is through a thorough dissection of controversial clinical and surgical modalities that we will find the path forward. Reference 1. ESCRS Endophthalmitis Study Group. Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg . 2007;33:978–988. Warmest regards, Abhay Vasavada Guest Editor EyeWorld Asia-Pacific Letters from the Editors Dear Friends I am extremely happy to present to you this issue of EyeWorld Asia-Pacific. This issue starts with an informative article addressing American ophthalmologists’ continued wariness about intracameral antibiotic use, followed by the Joint ASCRS/ ASRS Task Force findings and recommendations regarding hemorrhagic occlusive retinal vasculitis (HORV). Postoperative HORV is a rare but potentially devastating condition that can occur after otherwise uncomplicated cataract surgery. This disease may represent a delayed immune reaction similar to vancomycin-induced leukocytoclastic vasculitis 1 . The Task Force has issued a clinical alert regarding HORV’s association with intraocular vancomycin. Any ophthalmologist who experience or become aware of a case of HORV should report it to the HORV registry. Other controversial issues are discussed. First, this issue details the pros and cons of immediate sequential bilateral cataract surgery (ISBCS). Same-day bilateral cataract surgery is more convenient for patients, are safer and allow faster visual recovery. Opponents point to the risk of bilateral infection and elimination of the opportunity for the surgeon to learn from the first eye and make refractive adjustments for the second. In addition, lower reimbursement for the second eye poses a significant barrier for some. According to a Canadian study, both surgeries significantly improve patients’ quality of life and visual acuity. However, ISBCS may deliver certain additional benefits at the individual and societal levels. 2 This issue also compares small incision lenticule extraction (SMILE) with LASIK and other procedures. A study by Lee JK et al. found that the results of SMILE are similar to FS-LASIK. 3 One benefit of SMILE is lack a flap, which may cause complications. Also, SMILE is a virtually painless procedure. On the other side, SMILE may have slower visual recovery than LASIK, but some studies reported that long-term results of SMILE procedure are better. Further in this issue, limbal relaxing incisions are compared with toric IOLs for astigmatism correction. This issue also feature reports on the Combined Symposium of Cataract and Refractive Societies (CSCRS), a new approach to IOL power calculations, the management of astigmatism at the intraoperative stage, and gender inequality in some pediatric cataract surgery cases. In addition, physicians discuss use of loteprednol following LASIK and PRK, the successful use of mitomycin-C in corneal procedures, and intracameral prophylaxis of endophthalmitis. We should always be open to new knowledge and apply it wisely. As stated in Chapter 95 of the Tirukkural: Diagnose the illness, trace its cause, Seek the proper remedy and apply it with skill. Disease, its cause, what may abate the ill: Let leech examine these, then use his skill. References 1. Witkin AJ, et al. Postoperative Hemorrhagic Occlusive Retinal Vasculitis: Expanding the Clinical Spectrum and Possible Association with Vancomycin. Ophthalmology . 2015 Jul;122(7):1438-51. 2. Malvankar-Mehta MS, et al. Immediate versus Delayed Sequential Bilateral Cataract Surgery: A Systematic Review and Meta-Analysis. Plos One . 2015 Jun 29;10(6):e0131857. 3. Lee JK, et al. Femtosecond laser refractive surgery: small-incision lenticule extraction vs. femtosecond laser-assisted LASIK. Curr Opin Ophthalmol . 2015 Jul;26(4):260-4. Warmest Regards, S. Natarajan, MD Regional Managing Editor EyeWorld Asia-Pacific