EyeWorld India September 2018 Issue

September 2017 3 EWAP EDITORIAL 8 T his new issue of the scientifically enriched EyeWorld Asia-Pacific is out for the month of September, with new and fascinating Challenging Cases. Our cover features deal with interesting cases. For instance, read “Challenging cases in cataract surgery” to know how to manage an Argentinan flag sign during rhexsis. A comparison between phaco with miLOOP and phaco alone is also discussed in this issue. Meanwhile, the femtosecond laser has been shown to have the ability to create a perfectly round capsulotomy and perform nucleus fragmentation. Here experts discuss how to reduce effective fragmentation time using the femtosecond laser. At the same time, Zepto (Mynosys Cellular Devices, Fremont, California) is giving femto rhexsis some tough competition, according to our experts. There is also an exciting article on how cataract surgery may impact mortality risk, an article on premium implant cataract surgery talks about how cataract surgery is a two-step and not a one-step process, and an article on diagnostics deals with the role of corneal topography in refractive cataract surgery. Over the last three decades, refractive surgery has progressed and been refined into highly sophisticated procedures and the modern challenge of matching the right procedure to the patient is addressed. Percent tissue altered is a possible risk factor for ectasia in post LASIK patients with normal preoperative bilateral topography and is discussed in-depth herein. In our Cornea section, we discuss the effect of omega-3 fatty acid in dry eye management, while a corneal graft specialist looks at short- and long-term outcomes with PK and DALK in keratoconus. In this issue’s Device focus , surgeons share pearls and surgical results for the capsulotomy devices approved for the U.S. market in 2017, while the Pharmaceutical focus discusses hemorrhagic occlusive retinal vasculitis (HORV), which remains a concern for many practitioners. As always, I would like to conclude with a quote from Tirukkural : அறன்ஆக்கம் வேண்டாதான் என்பான் ப ிறனாக்கம் பேணாது அழுக்கறுப் பான். One who, in his envy, doesn’t appreciate the wealth of others, is known not to value virtue and his own wealth. (Tirukkural, Chapter 17, Quote 163) T he current issue of EyeWorld Asia-Pacific discusses many of the challenging cases and potential complications encountered in cataract and refractive surgery. The most serious potential complication, however, remains endophthalmitis following cataract surgery and one of the articles addresses recent concerns regarding the association of hemorrhagic occlusive retinal vasculitis (HORV) with intracameral vancomycin. Intracameral vancomycin has proved to be one of the most effective antibiotics for the prevention of endophthalmitis for several decades but understandably recent reports of HORVs has led many surgeons to consider alternative antibiotics. The most popular alternative intracameral antibiotics include cefuroxime, which was found to be effective in a randomized prospective controlled study conducted by ESCRS, and moxifloxacin. A retrospective study of the latter in 600,000 eyes in India showed a 3.5-fold reduction in the incidence of endophthalmitis. Commercial cefuroxime for intracameral use (Aprokam Theo Pharmaceuticals, UK) is available in Europe and moxifloxacin compounded for intraocular uses (Oromax, Orolab, India) is available in India and several other countries. Nevertheless, in several countries including Australia, these commercial preparations are unavailable. Compounding an appropriate solution of moxifloxacin from available IV preparations is challenging due to the low pH of moxifloxacin and disappointingly cefuroxime is not available in Australia. Cefazolin is widely used in some countries as an alternative but current evidence suggests that cefazolin may not be an ideal choice. We looked at the antibiotic sensitivity of endophthalmitis cases isolated between 2008 and 2017 in Perth, Western Australia, and only 46.5% were sensitive to the cefazolin as opposed to 100% sensitive to vancomycin and 89.8% sensitive to quinolones. To the best of my knowledge, only 39 eyes diagnosed with HORV have ever been reported despite the extensive use of vancomycin over more than two decades. In addition, the sole patient reported with HORV in which vancomycin was administered via intraoperative infusion had a subclinical presentation not requiring treatment with an excellent outcome. There is a risk associated with the administration of any intracameral antibiotic as well as the potential for TASS when these preparations are prepared in the OR. Considering that the reported risk of HORV with a low dose of vancomycin administered in the infusion appears to be less than when used as an intracameral bolus, the use of vancomycin in the former manner appears reasonable until suitable preparations with a comparable sensitivity profile become available. EWAP “ Considering that the reported risk of HORV with a low dose of vancomycin administered in the infusion appears to be less than when used as an intracameral bolus, the use of vancomycin in the former manner appears reason- able until suitable preparations with a comparable sensi- tivity profile become available. ” –Graham Barrett, MD Challenging Cases S. Natarajan, MD Regional Managing Editor EyeWorld Asia-Paci c Graham Barrett Chief Medical Editorial EyeWorld Asia-Paci c