Panel Discussion

Educational Objectives

The goal of this program is to improve the techniques used in, and increase the rates of success obtained with, refractive lens and cataract surgeries. After hearing and assimilating this program, the clinician will be better able to:

1. Identify appropriate patients for monovision.

2. Select patient for and perform intraoperative aberrometry.

3. Choose between cataract surgery alone and in combination with various filtration surgeries for patients with cataracts and glaucoma.

Summary

Second-eye syndrome: patients experience cataract surgery in second eye differently from first and remember events better; speaker explains it as normal differences between eyes; speculates it may result from higher level of anxiety experienced by patient during first surgery

Mini-monovision: panelist offers monovision but finds it difficult to determine which patients actually will do well with monovision; generally aims for emmetropia in both eyes; simulates monovision with contact lenses in candidates for LASIK, but not possible before cataract surgery

Next-generation implants: speaker anticipates development of technology to produce very small incisions, capsulotomies, and extraction of nucleus will stimulate development of new generation of IOLs

Comment about mini-monovision: many patients happy with difference of –1.25 D in nondominant eye and do not need glasses; used frequently with accommodating IOLs

Use of ORange (ORA) system: speaker does not use for every patient; primary indications include correction of astigmatism (either with relaxing incisions or toric lenses) and determining IOL power after LASIK; utility variable in eyes after radial keratotomy (RK); acquisition time — time needed to acquire image varies from 10 to 30 sec; acquires series of 40 images; good alignment required; procedure involves acquiring image, repositioning toric lens, acquiring another image, and repositioning again if necessary; entire process takes ≈2 min; viscoelastic — do not remove viscoelastic to acquire images because IOP influences result; overpressurization of eye eliminates any corneal astigmatism, and underpressurization of eye produces meaningless answers; speaker fills eye with hyaluronate; do not use Viscoat because of refractive surfaces within viscoelastic; removing viscoelastic and performing stromal hydration also affects corneal astigmatism; Healon EndoCoat also works well

Endoscopic cyclophotocoagulation (ECP) laser vs iStent for patients with glaucoma: approved by FDA only in conjunction with cataract surgery; studies show mean postoperative IOP of ≈16 mm Hg, which dictates appropriate patients for this device; patient population for both includes those on 1 to 2 medications with moderate glaucoma; choice determined by surgeon’s level of comfort with procedure; differences — iStent involves inserting device, while ECP potentially causes inflammation; iStent increases outflow, and ECP decreases inflow; ECP has longer history and well tolerated; one panelist puts patients on steroids (prednisolone) for ≈2 mo when using ECP; single iStent often insufficient (2 to 3 possibly required); Trabectome ablates meshwork and gives marginal benefit; single iStent showed effectiveness in trials at 1 yr but not 2 and 3 yr

Cataract surgery alone in patients with glaucoma: speaker performs cataract surgery alone if patient taking ≤2 glaucoma medications, unless disease very advanced (ie, 3 points of central fixation involved immediately around dead-center on 24-2 test pattern with very little optic nerve remaining); patients with such advanced disease receive filtration procedure; otherwise, even if patients have altitudinal defect with central fixation involved, those with ≤2 medications undergo cataract surgery alone and those taking ≥3 medications undergo filtration; rate of success of filtration surgery slightly lower if performed in combination with cataract surgery; possible to use oral carbonic anhydrase inhibitors (CAIs) and burp paracentesis if pressure rises in patients with glaucoma; ≈33% of patients have better control of IOP after cataract surgery and do not need medications for indeterminate length of time; ≈33% of patients have worse control and 33% remain same; filtration procedures include phacoemulsification and Trabectome or canaloplasty; iStent possibly helpful because canal procedures good at blunting immediate postoperative or perioperative spike in IOP

Causes of refractive surprise: unknown whether caused entirely by lens position; literature suggests various options ranging from not changing anything to adjusting by 100% for second eye if surprise encountered in first; speaker suggests 50% adjustment represents middle road; formulae diverge drastically for highly myopic eyes and those with steep or flat corneas; ORA can help with decision in these cases; panelists believe surprise caused primarily by lens position; posterior cornea may account for some; not possible to control how capsule contracts; another IOL formula shows effective lens position on average 33% of distance back from anterior capsule, but standard deviation large

Readings

Suggested Reading

Abell RG et al: Catalys femtosecond laser-assisted cataract surgery compared to conventional cataract surgery. Clin Experiment Ophthalmol Oct 19, 2012 [Epub ahead of print]; Bali SJ et al: Early experience with the femtosecond laser for cataract surgery. Ophthalmology 119:891, 2012; Bardocci A: Second-eye pain in cataract surgery. J Cataract Refract Surg 38:1705, 2012; Beiko GH: Comparison of visual results with accommodating intraocular lenses versus mini-monovision with a monofocal intraocular lens. J Cataract Refract Surg Oct 22, 2012 [Epub ahead of print]; Bhatt UK et al: Design and validity of a miniaturized open-field aberrometer. J Cataract Refract Surg Oct 27, 2012 [Epub head of print]; Buckhurst PJ et al: Multifocal intraocular lens differentiation using defocus curves. Invest Ophthalmol Vis Sci 53:3920, 2012; Calladine D et al: Multifocal versus monofocal intraocular lenses after cataract extraction. Cochrane Database Syst Rev 9:CD003169, 2012; Canovas C et al: Effect of corneal aberrations on intraocular lens power calculations. J Cataract Refract Surg 38:1325, 2012; Craven ER et al: Cataract surgery with trabecular micro-bypass stent implantation in patients with mild-to-moderate open-angle glaucoma and cataract: two-year follow-up. J Cataract Refract Surg 38:1339, 2012; Kwitko S et al: Orbscan II and double-K method for IOL calculation after refractive surgery. Graefes Arch Clin Exp Ophthalmol 250:1029, 2012; Linfield D et al: ‘Phaco-ECP’: combined endoscopic cyclophotocoagulation and cataract surgery to augment medical control of glaucoma. BMJ Open May 30, 2012 [Epub ahead of print]; Marchini G et al: Management of concomitant cataract and glaucoma. Dev Ophthalmol 50:146, 2012; Mello GR et al: Applications of wavefront technology. J Cataract Refract Surg 38:1671, 2012; Tang M et al: Intraocular lens power calculation after previous myopic laser vision correction based on corneal power measured by Fourier-domain optical coherence tomography. J Cataract Refract Surg 38:589, 2012; Wang L et al: Evaluation of intraocular lens power prediction methods using the American Society of Cataract and Refractive Surgeons post-keratorefractive intraocular lens power calculator. J Cataract Refract Surg 36:1466, 2012; Whang WJ et al: Comparison of refractive outcomes using five devices for the assessment of preoperative corneal power. Clin Experiment Ophthalmol 40:425, 2012.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Packer is a consultant for Abbott Medical Optics (part of Abbott Laboratories), Advanced Vision Science, Allergan, Auris Surgical Robotics, Bausch & Lomb, GE Healthcare, ISTA Pharmaceuticals, Ivantis, Rayner Intraocular Lenses, and VisionCare Corporate. He is also a consultant for and has equity in Corinthian Ophthalmic, LENSAR, mTuitive, NewSee, SURGiVIEW, Transcend Medical, TrueVision, and WaveTec Vision. Dr. Rhee is a consultant for Alcon, Allergan, Merck & Co, Novagali Pharma, and Santen Pharmaceutical Co, and has received research support from Alcon and Merck & Co. Dr. Serle is a consultant for Altheos, Forest Laboratories, and Ono Pharmaceutical Co Ltd; is on the Speakers’ Bureaus for Merck & Co and New World Medical; and has received research support from Aerie Pharmaceuticals, Akorn, Lexicon Pharmaceuticals, Novagali Pharma, PanOptica, and sanofi-aventis US. Dr. Steinert is a consultant for Abbott Laboratories. The planning committee reported nothing to disclose. In their discussions, Drs. Packer and Serle present information that is related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

p> The faculty spoke at 11th Annual Downeast Ophthalmology Symposium, held September 28–30, 2012, in Bar Harbor, ME, and presented by the Maine Society of Eye Physicians and Surgeons. To learn more about CME activities presented by the Maine Society of Eye Physicians and Surgeons, visit www.maineeyemds.com. The Audio-Digest Foundation thanks the speakers and the Maine Society of Eye Physicians and Surgeons for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OP510202

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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