DOC founder opens meeting’s 20th year with reflections, aspirations

NUREMBERG — One of the founders of the German Ophthalmic Surgeons meeting, Thomas F. Neuhann, MD, opened the meeting’s 20th year by reflecting on its modest beginnings and its future hopes.

The DOC annual meeting began as a 1-day conference in 1987 in Munich during a period marked by divides between office- and university-based ophthalmologists on rising trends such as phacoemulsification and IOL implantation.

“The beginning was characterized by resistance and difficulties,” Dr. Neuhann said, noting that only 100 to 150 participants attended the first meeting. “But the initial small meeting grew into a congress of peers.”

Dr. Neuhann acknowledged that it is difficult to predict what the future holds for the meeting, but that it should continue to reflect on the latest ophthalmic trends. He also hopes it will maintain its current atmosphere of professional camaraderie.

Invoking the words of Sir Harold Ridley, Dr. Neuhann told meeting attendees, “Even when a miracle is routine, it is still a miracle.”

Fishhook cataract extraction a viable option over phaco

A cataract extraction technique designed for clinics in developing countries is a viable option for difficult cataracts in the industrialized world, an ophthalmologist said.

Thomas F. Neuhann

Albrecht Hennig, MD, described his experience in Nepal using the “fishhook technique” he developed for cataract extraction.

According to Dr. Hennig, the technique, which involves extracting the whole cataractous lens through a self-sealing incision, is useful in countries where phacoemulsification machines are unavailable or in situations when a surgeon has problems with phaco.

“There is no doubt that the phaco technique is the best surgical technique at present, but even experienced phaco surgeons can get into trouble — for example, when there are very large, hard, brown cataracts, displaced lenses when they have a posterior pole cataract with a defect of the posterior capsule or when you have coloboma of the eyes,” he said.

Dr. Hennig illustrated this point with video demonstrating the extra energy required to break up a dense cataract.

“I just wanted to show you that there is always an opportunity if you don’t want to continue with the phaco, if you say there is enough energy spent on it, that you might also opt for this different approach,” he said.

Aspheric laser profile with phakic IOL the future of bioptics, physician says

The future of bioptics lies in the combination of an aspheric LASIK profile and a phakic IOL to match, one surgeon said.

Roberto Zaldivar, MD, said that the current practice at his clinic in Mendoza, Argentina, is to perform LASIK for astigmatism and then implant a phakic IOL the next day for optimal results. Dr. Zaldivar gave the Albrecht von Graefe Innovators Lecture.

According to Dr. Zaldivar, if a surgeon wants to consider bioptics as an option for a patient, an aspheric profile is the best choice to ensure a match with the subsequent phakic IOL.

“An aspheric profile is the best profile you can get for a future lens,” he said.

Trends in his own clinic have shifted over the years from a wavefront procedure over a phakic IOL implantation in 2001 to the simultaneous laser eye procedure and phakic IOL approach, Dr. Zaldivar said.

MMC useful in glaucoma surgery up to 5 years, but other options may be needed

Mitomycin-C is an effective tool for wound modulation up to 5 years after glaucoma surgery, but at 10 years, surgeons may have to combine it with other options, according to one ophthalmologist.

According to Paul Palmberg, MD, concerns that using MMC can lead to hypotony after procedures such as trabeculectomy are unwarranted.

“The use of mitomycin-C will never cause hypotony but will preserve the hypotony you create,” he said.

Rather than adjusting the use of MMC, Dr. Palmberg suggested that surgeons utilize certain techniques to prevent postoperative hypotony, such as adjusting scleral resistance to set a target eye pressure.

“This will make the surgery much more predictable,” he said.

Dr. Palmberg also suggested creating a “safety valve incision” to avoid late hypotony. In addition, he recommended applying sponges soaked with MMC to the eye for 2 minutes in primary cases or 5 minutes in repeat cases and using wide, fornix-based conjunctival flaps.

“MMC is great for 5 years, but 10 years and beyond we may need something else,” he said. “I hope 25 years from now some fellow here now may come up with something better.”

Ophthalmologists must do more to regulate costs of care

Ophthalmologists must promote the idea of disease prevention and work toward regulating the cost of expensive diseases, according to a speaker.

Guenter K. Krieglstein, MD, discussed the current general medical situation, particularly in ophthalmology. He described the situation as a “progress trap,” meaning that although the medical field has seen many positive developments, this progress has lead to a deterioration in health as patients live longer. This has created a mercantile approach to medicine, he said.

“The system wants more and more and is never satisfied,” Dr. Krieglstein said.

In addition, the definition of health, as created by the World Health Organization, perpetuates the idea that health is a state of complete biological and psychological well-being.

“A more practical notion would be that health is the strength to understand how to live with disturbances and disorders,” he said.

A lot of these factors can lead to cost pressure, which doctors can control by creating guidelines regarding the therapeutic value, clinical relevance and cost efficiency of new procedures, Dr. Krieglstein said. Such guidelines should be independent of influences such as from manufacturers, he noted.

“If we lose ownership and responsibility, we can’t get out of the trap,” he said. “The gatekeeping function of physicians must be used in a more determined and efficient way as a regulating instrument.”

Accommodating lenses the primary focus of presbyopia research, surgeon says

Despite much attention focusing on multifocal IOLs, accommodating lenses are leading research efforts in the field of presbyopia correction, according to a surgeon.

Samuel Masket

Multifocal IOLs are a viable option for patients with presbyopia, but such lenses have some drawbacks, Samuel Masket, MD, said in the Ridley Lecture.

“Multifocal lenses divide light energy, and by dividing these energies, the patient becomes more susceptible to ametropia,” Dr. Masket said. “We need to be aware that the division of light will cause undesired optical side effects in a certain proportion of patients.”

The number of accommodating lenses in the research pipeline reflects this shifting opinion, he said.

In addition to well-known lenses being investigated, such as the Visiogen Synchrony dual optic IOL, Dr. Masket discussed several lens designs being developed, including the NuLens (NuLens Ltd.) and the Liquilens (Vision Solution Technologies).

The NuLens, which is just beginning human trials, features a silicone center and a PMMA ring designed for implantation in the ciliary sulcus on top of the lens capsule, he said.

The Liquilens features an optic that is filled with two fluids. These fluids have different refractive indices and are designed to shift as the eye changes position, Dr. Masket said.

“A large amount of energy is being channeled into accommodating lenses,” he said. “It is evident that this is the direction that we will be headed, and we’ll reach the final frontier in the foreseeable future.”

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