EyeWorld India September 2016 Issue

September 2016 72 EWAP NEWS & OPINION 29 th APACRS - from page 71 not using a default A-constant for optical biometry. For premium lenses, Dr. Hutauruk said to use a manual keratometer. He said to be sure not to use an obsolete formula, like the SRK I or II. Always measure both eyes, and remeasure both eyes in special conditions, he said. His last tip was for a personalized A-constant. Robert Ang, MD , Manila, Philippines, highlighted the topic of small pupils in his presentation. Management of small pupil starts with recognizing the problem, he said. Dilating the pupil during screening/checkup prior to surgery is important, he said. This includes checking the retina, measuring potential visual acuity, and measuring the size of the dilated pupil. Planning for surgery is also affected with small pupils, Dr. Ang said, because if the patient wants the femtosecond laser, this could be impacted. If the pupil doesn’t dilate, you cannot proceed, he said, so you may have to tell the patient that the femtosecond laser is not an option. You also have to prepare your instruments and devices, he said, as well as manage expectations. Some causes of a small poorly dilating pupil include diabetes, pseudoexfoliation, synechiae, or unidentifiable reasons. Dr. Ang said that, with these pupils, you have increased the degree of difficulty of the surgery. He shared his dilating drops protocol that he said should be strong enough for most pupils. Although this is not a common problem, Dr. Ang said surgeons need to be prepared. LASIK and other refractive procedures discussed in symposium At a symposium on laser refractive surgery, topics discussed included the LASIK flap, refractive surgery in Korea, SMILE, management of dry eye after refractive surgery, and refractive surprise, among others. In the session, Kyung Chul Yoon, MD , Gwangju, South Korea, discussed optimal management of dry eye after refractive surgery. Dry eye incidence is almost 50% at one week after surgery, he said. Additionally, dry eye after LASIK can persist up to six months to a year. But this also depend on the degree of myopia, depth of ablation, type of surgery, and other factors. Dr. Yoon highlighted specific management options for dry eye after cataract and refractive surgery. These options include artificial tears, anti-inflammatory agents, mucin secretagogues, serum, and punctal plugs. In summary, he said that ocular surface disorders are one of the major problems after refractive surgery, especially in patients with preexisting dry eye. Routine perioperative evaluation of dry eye is important before refractive surgery, Dr. Yoon said. Combined treatment of ocular surface problems is important before and after refractive surgery, especially in patients with preexisting dry eye. Cataract conundrums When you see a patient the day after surgery—“And I do encourage you to see your patient a day after surgery,” Cesar Espiritu, MD , Manila, Philippines, said—with a cloudy cornea and poor vision, your heart, Dr. Espiritu said, “really drops.” In patients like these, he said, you are dealing with one of two of the most depressing potential complications of cataract surgery: toxic anterior segment syndrome (TASS) or infectious endophthalmitis. Dr. Espiritu discussed these conditions at the “Cataract Conundrums” symposium. Infection is, of course, right up front, the more frightening prospect. Still, he said, “TASS isn’t a thing to be brushed aside.” TASS, he said, can induce permanent corneal endothelial damage. It can also induce glaucoma due to permanent damage to the trabecular meshwork. “Depending on the type and duration of the toxic insult, the visual outcome can range from 20/20 to no light perception,” he said. “Patients may require further intraocular procedures, such as penetrating keratoplasty and/ or glaucoma filtering procedure surgery to regain visual function.” The surgeon needs to recognize and manage the problem early enough to avoid these consequences, Dr. Espiritu said, and the immediate task is to differentiate inflammation from infection. There are a number of variable differences between TASS and endophthalmitis, but the surest signs are vitritis—rarely present in TASS, always present in endophthalmitis—and response to steroids—dramatic improvement in TASS, equivocal response in endophthalmitis. Dr. Espiritu thus recommends beginning with a steroid challenge—prednisolone acetate 1% or dexamethasone eye drops every 10 minutes—and a cycloplegic dilator to examine the vitreous and retina. His acute management also includes aggressive, broad spectrum antibiotics every 15 minutes. If uncertain, Dr. Espiritu recommended treating the worse condition. Should the surgeon determine the case is one of endophthalmitis, the patient should be admitted, specimens for stain, culture, and sensitivity testing collected, parenteral and intraocular antibiotics initiated, vitrectomy and intraocular lens explantation performed.