‘Telling It Like It Is!’ sums state of cataract surgery

Take-home

Challenging surgical cases, controversies, and the management of surgical complications were the focus of the third annual “Cataract Surgery: Telling It Like It Is!” meeting.

By Zaid Smith, PhD

Sarasota, FL-Candid. No-holds-barred. Highly clinical. State of the art. For the third consecutive year, cataract surgeons gathered here in January for “Cataract Surgery: Telling It Like It Is!” with an agenda ready to deliver on these goals.

The extended-weekend conference was organized by Robert H. Osher, MD, professor of ophthalmology, University of Cincinnati, and medical director emeritus, Cincinnati Eye Institute. Dr. Osher established the meeting without continuing medical education units so as to be able to mention new products, drugs, and off-label advances in surgical technique.

“The goal of this meeting is to provide the best quality, useful education with total honesty and without censorship,” Dr. Osher said. “We want every attendee to depart Sarasota more confident about delivering the best possible surgical care.”

With a capacity crowd of nearly 400 attendees and 80 exhibitors, this pioneering educational approach appears to fill an unmet need in the cataract surgery community.

This year’s faculty included:

• Richard Mackool, MD, director, Mackool Eye Institute and Laser Center, Astoria, NY;

• Warren Hill, MD, medical director, East Valley Ophthalmology, Mesa, AZ;

• Ike Ahmed, MD, assistant professor of ophthalmology, University of Toronto and clinical assistant professor of ophthalmology, University of Utah, Salt Lake City;

• Michael Snyder, MD, voluntary assistant professor of ophthalmology, University of Cincinnati and in private practice, Cincinnati Eye Institute;

• Robert Cionni, MD, medical director, The Eye Institute of Utah, Salt Lake City and adjunct clinical professor of ophthalmology, University of Utah, Salt Lake City;

• Graham D. Barrett, MD, clinical professor, Lions Eye Institute and Sir Charles Gardner Hospital, Perth, Australia;

• William Fishkind, MD, clinical professor, University of Utah, Salt Lake City, clinical professor, University of Arizona, Tucson, AZ, and director, Fishkind, Bakewell & Maltzman Eye Care and Surgery Center, Tucson, AZ;

• Lisa B. Arbisser, MD, ophthalmologist for Eye Surgeons Associates, Iowa and Illinois Quad Cities; and adjunct associate professor, John A. Moran Eye Center, University of Utah, Salt Lake City;

• Robert Weinstock, MD, director, Cataract and Refractive Surgery, The Eye Institute of West Florida, Largo, FL, and assistant clinical professor of ophthalmology, University of South Florida, Tampa.

The education unofficially began Wednesday evening with a pre-meeting movie night for ophthalmologists who arrived a day early. While the nearly 100 attendees enjoyed dinner, Dr. Osher presented 10 video clips from the library of the Video Journal of Cataract and Refractive Surgery and led an interactive discussion of each.

On Thursday, the meeting opened with a new technology symposium featuring a format that Dr. Osher called “Showdowns,” with side-by-side comparisons of similar technologies, as presented by physician advocates. Phacoemulsification machines, microscopes, presbyopia-correcting IOLs, toric lens alignment technology, biometry equipment, and femtosecond lasers for cataract surgery were reviewed in detail.

Rings and things

On Friday morning the session opened with a tutorial called “Rings and Things,” in which Drs. Ahmed and Cionni discussed the use of zonular and pupil expansion devices, including capsular tension rings (CTRs), capsular tension segments (CTSs), and capsule retractors in cases of zonular dialysis or deficiency. There was some debate on the timing of CTR placement.

Dr. Cionni maintained that “the best time is after phacoemulsification, after all capsule has been cleaned and you have a good view, to be certain of being in the right place and that there’s no capsular opening.”

While agreeing that there were advantages to the late placement, Dr. Ahmed had a different take, preferring CTR placement prior to phacoemulsification and cortex removal in most cases.

“The time to insert a CTR is when you need it,” Dr. Ahmed said, adding that Dr. Cionni’s late placement timing was an acceptable alternative, though requiring much viscoelastic to keep the capsule open and structurally intact.

Dr. Cionni replied that with experience, late CTR placement becomes more comfortable. In early placement, the addition of a safety suture in the leading eyelet can both help insert the CTR and rescue it, should the capsule be broken during phacoemulsification.

Both presenters agreed on the importance of the generous use of dispersive viscoelastic in the anterior chamber to prevent vitreous from coming forward into the zonular weakness, of keeping the capsule expanded with viscoelastic throughout the procedure, and of the utility of CTR injectors. With early placement of the CTR, cortex can be caught on the ring, but this annoyance can be minimized with the scalloped Henderson CTR design.

Attention then turned to videos of cases where a CTR was used to provide circumferential tension, along with a CTS (or two) providing more localized support. Devices highlighted in this setting included the Mackool and MST capsule retractors, the FCI Model MR-1G CTR, and GORE-TEX sutures for securing the capsule to the sclera. The latter, although an off-label use, were said to have less leakage and chance of breaking than other suture materials.

The next event was a symposium on complications, conducted by Dr. Osher. A wide range of videos was shown, demonstrating the management of thermal injury, iris prolapse, conjunctival ballooning, capsular tears, positive pressure, flying cannulas, bleeding, inverted IOLs, tears in Descemet’s membrane and zonulae, and damaged egos.

“If you operate, you will get complications,” Dr. Osher said. “You get the best outcomes when you expect and prepare for the worst. If you encounter a complication, don’t deny, don’t delay, and know how to manage it.”

Situations and decisions

Dr. Hill presented a symposium titled “Situations and Decisions,” a compilation of ways to stay out of trouble when determining IOL power calculations and making IOL selections.

“One recurring problem is that most ophthalmologists are still stuck in the 1990s in terms of the use of formulas they use,” Dr. Hill said.

Ophthalmologists can do much better than the older two-variable, third-generation formulas, he noted. For those physicians who take the time to track their outcomes, 74% to 82% of patients are within 0.5 D of the target refraction.

What formula is best overall?

The Haigis formula uses three lens constants (a0, a1, and a2) and can be optimized to match the individual geometry of individual IOL models. This formula is available on many biometers. Visit the Haigis Users Group for Laser Interference Biometry site, originated by Wolfgang Haigis, PhD, at www.augenklinik.uni-wuerzburg.de/ulib/c1.htm.

Overall theoretical formulas are Holladay 2 and Olsen, but they require more measurement information. However, they offer improved accuracy. Dr. Hill himself uses the Olsen formula, although he said that the software interface can sometimes be difficult to use. Emerging engineering-based statistical models for IOL power calculations are currently being developed that promise even better results.

Dr. Hill offered several Web-based resources to help minimize refraction and astigmatism errors in IOL calculations, including www.astimatismfix.com to determine if a toric lens is properly placed; www.SIA-calculator.com for calculating how much astigmatism is created during cataract surgery; and the ASCRS calculator, which has become an indispensible tool for IOL power calculations after refractive surgery. Links to these and other resources are also found at www.doctor-hill.com/iol-main/iol_main.htm.

Then, in a rapid-fire session, Dr. Osher posed to Dr. Hill numerous situations demanding tough clinical decisions, including monovision, piggybacking, and IOL changes on the operating table.

Going 3-D

After an afternoon of vitrectomy and glaucoma procedure wet labs, participants were treated to an evening at the movies with three-dimensional (3-D) videos. Drs. Weinstock and Ahmed discussed cases using TrueVision’s 3-D visualization during surgery. Effective use was made of the 3-D medium to show bimanual dissection techniques following femtosecond laser capsulorhexis in a range of challenging cases.

“One of the paramount benefits of laser technology is safer cataract surgery and faster recovery,” Dr. Weinstock said.

Dr. Ahmed then showed a traumatic case of a subluxed cataract and atonic pupil, demonstrating the use of zonular techniques and CTR placement. In the 3-D presentation, the lens tilt and the complicated spatial relationships were clearly visible. In Dr. Ahmed’s opinion, 3-D surgery was easy to learn.

“The first day with TrueVision, I thought I would play around with it for an hour,” he said. “But it stayed on the microscope all day, and we used it for a list of complex cases.”

Dr. Mackool followed with a two-part presentation, “3-D, OR and Office Pearls.” In the first part, he explained, “it’s never been more important to make good use of your time, since you’re being paid less for it.”

He offered dozens of tips and techniques for improving efficiency, including having patients fill out questionnaires at home prior to the office visit, which, in turn, allows an estimation of the time to schedule for each case. Having technicians do everything possible before the consultation shortens and improves the consultation.

“The more that’s done before you get to the patient, the more data you have when you consult with the patient,” Dr. Mackool said.

A wide range of appropriate handouts for patients to read while dilating patients’ pupils saves explanation (and repetition) time.

“If you take nothing else from this meeting, go home and make handouts,” he said. “You’ll see twice as many patients.”

In the second part, Dr. Mackool demonstrated in 3-D with his Sony system other techniques for improving operating efficiency and outcomes, including reducing the incidence of posterior capsule tear (keeping the chopper posterior to the phaco tip is one key), and decreasing the time to change instruments.

“It isn’t that the steps inside the eye are done crazy fast,” he said. “It’s that the steps outside the eye are done superfast.”

The early evening session concluded with “Friday Night at the Movies,” conducted by Dr. Fishkind, head judge at the American Society of Cataract and Refractive Surgery Film Festival. He selected his favorite videos from the past three decades, keeping the audience on the edge of their seats.

A novel session called “Late Night With Ike and Warren” drew about 80 ophthalmologists from 10 p.m. to midnight. Attendees enjoyed the opportunity to ask questions in a smaller, more intimate setting.

At the ready for vitrectomy

Saturday morning featured Drs. Arbisser and Fishkind discussing ways of preventing and managing unexpected vitrectomy in their session “Oops . . . Vitrectomy!”

In a thorough and fast-paced presentation, Dr. Arbisser showed the principles for avoiding vitrectomy and various techniques for managing dangerous situations. Much attention was given to ways of elevating and retrieving descending lenses, including spearing from anterior incisions and visco-levitation, as well as pars plana approaches to anterior vitrectomy.

Both presenters stressed the importance of advance preparation, including having a vitrectomy kit set aside with all the tools needed, and having staff trained in what to do. Dr. Fishkind added that having a card in that kit with the machine settings for vitrectomy was useful-especially distinguishing between “Cut IA” and “IA Cut.”

A high cutting rate is worth acquiring, in his view, since “with the newer high cutting-rate machines, the vitrectors act like ice cream scoops, allowing them to be used as surgical instruments.”

He also stressed the importance of managing all the other problems before calmly proceeding with the vitrectomy.

Challenging cases

In the “Challenging Case” symposium, Drs. Snyder and Ahmed showed how they negotiated a series of difficult cases, including intumescent white cataract, very small pupils, lens iris diaphragm retropulsion, posterior polar cataract, trauma, iris prolapse, uveitis, congenital lenticonus, and “insanely dense ‘catarocks’,” among others.

“I like to think of each case as being the roughest case of the day-until it’s over,” Dr. Snyder said. “And then, the next one is. When you think a case is going to be routine, you get in trouble.”

Some of the devices highlighted as being particularly useful in difficult situations were GORE-TEX sutures (off-label), Malyugin rings, iris prostheses (not FDA approved), the Colvard (Oasis) and Malyugin (MST) pupil expanders, Kuglen hooks, and intraoperative gonio mirrors.

Dr. Osher presented the International Award to Dr. Barrett, “the most interesting person in the world,” for his teaching, his innovations in surgery, IOL design, videography, and for his efforts on behalf of the Australasian Society of Cataract and Refractive Surgeons and the Asia-Pacific Association of Cataract and Refractive Surgeons. (See “Dr. Barrett in international spotlight”)

Peri-operative medications

The lunch symposium on “Peri-Operative Medications” featured a panel that included:

• Johnny L. Gayton, MD (Eyesight Associates, Warner Robins, GA);

• James Gills, MD (St. Luke’s Cataract and Eye Institute, Tarpon Springs, FL);

• Anup K. Khatana, MD (Cincinnati Eye Institute, Cincinnati, OH);

• Deepinder K. Dhaliwal, MD (associate professor of ophthalmology, University of Pittsburgh).

Dr. Osher moderated, asking a series of quick questions and eliciting quick answers (from both panel and audience) in response.

There was a range of opinion on which steroid to use, and a lively discussion of difluprednate (Durezol, Alcon), which Dr. Dhaliwal characterized as “a steroid on steroids.” The acceptance of nonsteroidal anti-inflammatory drugs continues to rise, although cautions were expressed in regard to the use of generic agents.

Frustration was expressed with the current state of innovation in anti-infective agents, which was laid at the FDA’s door. Dr. Gills shared his success in avoiding endophthalmitis (0/75,000 cases) using intracameral vancomycin/ceftazidime only.

“I transfer the cost and the responsibility of fighting infection from them to me, and it saves them about $400,” he said.

More conventional approaches included besifloxacin (Besivance, Bausch + Lomb), moxifloxacin (Vigamox, Alcon), and polymixin B/trimethoprim (Polytrim, Allergan). Alcon’s ganciclovir (Zirgan) received high praise when the discussion turned to antiviral agents. Approaches to patients with glaucoma and blepharitis rounded out the session.

After lunch, a wet lab on “Advanced Suturing” was led by Dr. Snyder, with an emphasis on iris fixation and repair using Siepser, horizontal mattress, and cow-hitch knots. Participants could work with the GORE-TEX 9-0 and 10-0 sutures, which were not off-label for use on plastic bowls and pantyhose.

Additional labs were offered, including a risk management session led by Bradley Fouraker, MD, of Brandon Cataract Center and Eye Clinic, Brandon, FL. OMIC offered a 5% to 10% discount on annual insurance premiums for the completion of the lecture.

The afternoon tutorial on “Minimally Invasive Glaucoma Surgery,” was presented by Drs. Ahmed and Steven Vold, MD (Vold Vision, Fayetteville AR), and focused on the use of the iStent G1 trabecular bypass stent (Glaukos), the CyPass microstent (Transcend Medical), and the EX-PRESS glaucoma filtration device (Alcon). Dr. Khatana then reviewed indications and techniques for trabectome (including strengthening the deltoids, better maintaining proper hand position).

Toric IOLs

In the tutorial on “Toric IOLs,” Dr. Hill discussed ways to use toric IOLs properly, in particular, determining the orientation of the steep and flat meridians and the power difference between those meridians-thinking like the calculator.

“The Ks that you used to calculate the spherical power of the IOL can be completely different [from] what you use for the toric calculators,” he said. “It's helpful to keep in mind that you’re not just getting a set of Ks.”

Dr. Osher noted that the adaptation of the toric lens has lagged, because of a lack of confidence in the diagnostics and in nailing the target meridian. He exhorted the audience to use toric IOLs now.

“No conscientious person would do a refraction, find significant cylinder, and only prescribe the sphere,” Dr. Osher said. “In the operating room, each of us must strive to be a skilled refractive cataract surgeon.”

To help facilitate the goal of toric adoption, Dr. Osher shared tricks on interpreting manual K, automated K (using either the Haag-Streit LenStar or the Zeiss IOLMaster), topography (Zeiss Atlas), and aberrometry (WaveTec ORA System and Clarity Holos).

He then explained how to work with emerging technology in a practical manner with a video demonstration.

“You may not be as perfect as possible, but you’ll still help the patient with a toric lens,” he reassured participants.

“IOL Repositioning/Exchange” was discussed and demonstrated in alternating cases by Drs. Snyder and Mackool. Useful tools included the Snyder-Osher IOL holding forceps and serrated scissors to remove IOLs, the high-speed (at least 2,500 cuts per minute) 23-gauge vitrectomy cutter for converting capsular tears, and the ultrasound biomicroscope for measuring chamber depth.

Drs. Osher and Barrett sequestered the young ophthalmologists for a dinner session titled “Ask Anything.” Attendees were encouraged to bring up questions and issues without restrictions during this innovative teaching experience.

Iris reconstruction

Sunday morning started with a session on “Iris Reconstruction” by Dr. Snyder. In his experience, there are three ways to repair the iris. The first approach is by stretching and re-apposition. For this, the Siepser knot is key and was carefully explained. Usually, 2.5 clock hours is the largest area that can be covered. Dr. Snyder uses 10-0 prolene with the Ethicon CTC-6 needle. Microforceps developed by Dr. Ahmed were endorsed for anterior chamber tying.

Iris sculpting is a second approach, with numerous variations, including YAG laser, scissors, and vitrector. Scissors work well on adhesions and scarring without tissue loss. The 23- to 27-gauge vitrector can be used to reshape the pupil.

“It’s like the eraser tool in Photoshop,” he said. “The only problem is there’s no undo button, so do it slowly.”

The pupillary cerclage method of Greg Ogawa, MD, was also detailed. The MST capsulorhexis forceps developed by Barry Seibel, MD, received praise for iris work.

Finally, Dr. Snyder showed the use of iris prostheses-a problematic area, given that none are presently FDA-approved, not even for compassionate use.

“But I do want to show these devices anyway, because you might want to send your patients to Canada, or Europe, or Asia, or South America,” he said, before discussing Morcher and Humanoptics devices. The Humanoptics CustomFlex iris was singled out as being exciting, but cautionary tales were told of the Morcher 30-B and NuColorIris devices.

Favorite tools

After breakfast, the seminar “My Favorite Instruments” featured Drs. Weinstock, Arbisser, Barrett, Mackool, Snyder, and Osher presenting short videos showing the use of their favorite operating room tools. Dr. Weinstock led off with the other hand as the most important tool, making a case for bimanual surgery. He then showed the microcapsulorhexis forceps with interchangeable tips (Storz) and the 0.4-mm irrigation/aspiration (I&A) port (used with a Venturi pump).

Dr. Arbisser told about her chopper of choice (Rosen Phaco Splitter) and about nuclear spears (Epsilon) from an anterior approach for rescuing a descending nucleus.

Dr. Mackool featured the long, thin capsulorhexis forceps (Crestpoint Management), the 22-gauge hydrodissection cannula, and viscodissection, in general.

“There can’t be a downside to [viscodissection’s] use, and most people find they have a lower posterior capsule rupture rate,” he said.

The Mackool big ball chopper spatula, 0.25-mm I&A tips, and the Mackool (Jr.) titanium toric axis marker (both Crestpoint Management) rounded out his selections.

Dr. Snyder highlighted the Snyder-Osher forceps and serrated scissors (Crestpoint Management) for IOL removal, the 23-gauge Seibel capsulorhexis forceps (MST), and Snyder ruler (MST), with markings up to 16 mm.

Dr. Barrett mentioned his Phaco Axe, but concentrated on the second-generation I&A cannula of his design (MST).

Dr. Osher finished the session with presentation of a magnifier (Bausch + Lomb), the Wet-Field Thermodot (Beaver-Visitec International) for orientation marking, an internal flare knife, a capsulorhexis ring (Crestpoint), a bevel-down phaco tip (Alcon), a “mature” chopper, a “double-finger” chopper, intraocular forceps and scissors (Crestpoint), a new Malyugin ring injector (MST), and 27-gauge curved cannulas for dry cortical removal (Bausch + Lomb, Crestpoint).

Lessons learned

The faculty then presented a session of “Cases that Taught Us Something.” Dr. Weinstock showed a cataract surgery done entirely through 1-mm incisions, using instrumentation from MST.

“It’s not that this case taught me anything about this particular eye, but it taught me something philosophically, that what we do will continue to get better for us and better for our patients,” he said.

Dr. Arbisser discussed a trauma case with extensive free vitreous around zonules with a failed attempt to secure the bag.

“When using a pars plana approach for the anterior vitrectomy it is possible to breach the posterior capsule, leading to a dropped nucleus,” she said.

Dr. Hill showed a patient whose confusing post-surgical recovery led to the fortuitous discovery of a meningioma that had coincidentally begun impinging on the optic nerve at about the same time. Luckily for the patient, the immediate postoperative period is a time when everyone is paying close attention.

Dr. Hill reminded the audience that things are not always as they may appear and referred to Hickam’s dictum that commonly is stated as patients can have as many different diagnoses as they damn well please. He was given a loud round of applause.

Dr. Snyder showed a case demonstrating that “things follow pressure gradients: the number one lesson in ophthalmology. Something I think about in every case is where are the favorable and unfavorable gradients.”

Dr. Barrett showed a nanophthalmos case, with the lessons learned when operating in “a small world.”

Dr. Osher reviewed a case of intraoperative iris disinsertion that taught him never to sew inside the eye, but rather to use the Siepser sliding knot suture, and a case of a projectile cannula that taught him “every cannula is a potential missile. Always pinch the cannula tightly, and direct the tip perpendicular to the lateral border of the incision before injecting.”

The conference ended with the session, “What the Hell Was That?” in which Dr. Mackool showed videos of bizarre phenomena and situations encountered during surgery, described with humor and insight. One of the incidents was a little piece of plastic appearing suddenly in two consecutive eyes, but only in a certain operating room. A search of the operating room trashcans revealed that the plastic phaco wrenches were being stripped on use by a new (and considerably more muscular) technician in that operating room, with the result that bits were being dispersed into the eye.

Dr. Osher showed a final video emphasizing the importance of balancing the challenges and joy of practicing cataract surgery with life’s other priorities. Attendees departed Sarasota ranking this meeting among the “best ever,” which explains the packed house for 3 years running.

The next "Cataract Surgery: Telling It Like It Is!" conference will be held Jan. 15 to 19, 2014.

Dr. Barrett in international spotlight

Sarasota, FL-In his “International Spotlight” talk, Graham Barrett, MD, reviewed his contributions to many areas of cataract surgery. He began with discussing some of his contributions to IOL (haptics) design, including the design of the first single-piece soft lens, open-loop flexible haptics, and preloaded IOL insertion.

“When it comes to haptics design, it’s not just the structure, but the adhesiveness of the material [that] has a huge influence,” he said.

He then turned to phacoemulsification techniques and fluidics, showing how Venturi pumps result in shorter nucleus removal times, and how using a phaco-axe rather than sculpting and grooving reduces phacoemulsification energy, followed by how balancing continuous longitudinal ultrasound with incision size and aspiration rate yields optimal results.

Dr. Barrett next discussed solutions for presbyopia, advocating “modest monovision” (–1.25 D) for patients with potential acuity greater than 6/9 in both eyes, using the Hoya model 751 lens.

“The optimum quality of vision is not just about resolution, but is about the balance between good resolution and depth of focus,” he said.

He concluded with a discussion of improving IOL prediction. In postLASIK patients, Dr. Barrett showed better results using the “True-K Formula.” Patients with extreme myopia benefit from the Barrett Universal Formula that accounts for the change in vergence between positive and negative lenses. The variable accuracy of power prediction in hyperopic, myopic, and average eyes can be reduced using the universal formula, compared with the SRK/T, Holladay I, Haigis, and Hoffer Q formulas.

After the presentation, Dr. Osher conducted an interview elucidating more of Dr. Barrett’s life, including his passion for astronomy, fly fishing, family adventures, video production, and cataract surgery.

Dr. Barrett said he fell in love with the surgical procedure because “cataract surgery is the most magnificent operation, and the greatest gift to our patients.”