Improved techniques and products generate excitement at Rome meeting

This year’s joint meeting focused on newer lenses and advanced cutting techniques.

ROME — Advances in medical treatment for glaucoma have greatly reduced the need for combined cataract-glaucoma surgical procedures, according to a physician speaking here.

Richard L. Lindstrom

“In the past I used to perform a lot of combined procedures. Now I have reduced them to only one or two a year,” said Richard L. Lindstrom, MD, global chief medical editor of Ocular Surgery News. Dr. Lindstrom gave the Benedetto Strampelli Medal Lecture here during the Italian Society of Ophthalmology annual meeting. In his lecture on cataract surgery in glaucoma patients, Dr. Lindstrom outlined special considerations and precautions for cataract surgery in this population.

Most patients with glaucoma who are seen by a comprehensive ophthalmologist because of visual impairment from cataract can be treated with cataract surgery and lens implantation alone, Dr. Lindstrom said. Phacoemulsification with posterior chamber IOL implants lowers the IOP of a patient by an average of 2 mm Hg to 4 mm Hg, and “every millimeter of mercury reduction lowers the risk of visual field loss by 10%,” he said.

Combined phaco-trabeculectomy procedures “have only marginally better results” with IOP lowering, Dr. Lindstrom said.

“Intraocular tension might be lowered 3 to 6 mm Hg, but the risk of complications, short and long term, is much higher and visual recovery is significantly slower than after cataract surgery alone,” he said.

Cataract surgeons who operate on glaucoma patients must consider the negative effects the eye may have experienced from the disease itself, from chronic use of medications and, more important, from the preservatives contained in those medications.

Clear corneal cataract surgery spares the conjunctiva in case glaucoma surgery is required later, Dr. Lindstrom said. He recommended creating a small incision in clear cornea, “never invading the conjunctiva.” Endothelial abnormalities are likely to be present, and the endothelial reserve reduced, so specular microscopy and pachymetry should be performed preoperatively to assess the condition of the cornea.

If the patient’s pupil is very small – another effect of chronic medication – “it can be enlarged by simply using iris retractors,” he said.

Extra care must be taken intraoperatively with the use of viscoelastics, which can block outflow channels if left in the eye.

Dr. Lindstrom said implantation of a capsular tension ring may be helpful in some patients. He said IOL placement is sometimes a challenge.

“I normally implant the lens in the bag, but if the capsule is very loose, I place the lens in the sulcus, with the optic captured in the bag,” he said.

To reduce the inflammation that can be seen due to drug preservatives, Dr. Lindstrom asks patients to discontinue use of any potentially inflammatory drug a few days before surgery. In some cases he prescribes nonsteroidal anti-inflammatory drugs and steroids preoperatively.

Inflammation can also complicate outcomes postoperatively, Dr. Lindstrom noted.

“Watch out for cystoid macular edema, which is also quite commonly caused by drug preservatives,” he said. Prophylactic treatment for postop pressure spikes is also advisable, he added.

A higher rate of Nd:YAG laser capsulotomy is to be expected in these patients, in whom capsular fibrosis and capsular phimosis are more frequent.

Dr. Lindstrom’s lecture was presented at the joint meeting of Ocular Surgery News, the Italian Society of Ophthalmology, the Italian Association of Cataract and Refractive Surgeons and the International Society of Refractive Surgery/American Academy of Ophthalmology.

More presentations from the conference are highlighted in the remainder of this article. These items appeared first on the OSNSuperSite as daily reports from this meeting. Look to upcoming issues for expanded coverage of selected items.

IOL rates high on quality of life improvement

Richard B. Packard

Patients who are bilaterally implanted with a multifocal IOL report a high level of appreciation for the implant, according Richard B. Packard, MD, FRCS, FRCOphth.

“The vast majority of patients are able to read without glasses and only a few need them for intermediate tasks,” Dr. Packard said. “Night vision disturbances are minimal, and, above all, almost all of these patients would recommend [the ReSTOR] to friends and relations.”

He said he has implanted the ReSTOR (Alcon) IOL in 240 patients since October 2003. He sent a questionnaire to 40 patients with a follow-up of more than 1 year to investigate their response to “real life” with the IOL. Patients were asked to rate their visual comfort in a series of daily activities on a scale of 1 (low) to 7 (high), and were asked about their spectacle use. Other study topics included driving comfort in daytime and nighttime conditions, glare and halos.

“The results for near and distance vision approached 7 in bright light and were also acceptable for dim light,” Dr. Packard said.

The majority of the patients could manage “very well” without reading glasses, and of the 30 patients who use the computer, only five said they wear glasses specifically for that purpose. Patients who play cards — representing a high percentage of the group — reported “absolutely no problem” playing without spectacles, Dr. Packard said.

Patients were very happy with their driving vision during the day and at night, he said. The vast majority felt they had no significant problems with glare or halos. Six patients reported some night vision disturbances, which was not deemed serious enough for them to stop driving at night.

Of the 40 patients, 35 said they would recommend the lens, he said.

IOLs can be low vision aid for AMD patients

Diffractive multifocal IOLs can be effective low vision aids in eyes that have undergone either cataract surgery or refractive lens exchange and also have macular disorders, according to one surgeon.

“We are currently using the ReSTOR (Alcon) for this new purpose in Greece, and results are remarkably better than with monofocal IOLs, due to the higher magnification and pseudoaccommodative effect of this type of lens,” said Spyros Georgaras, MD.

He implanted the ReSTOR in 27 eyes of 20 patients who had slight to severe visual impairment as a result of age-related macular degeneration. Patients were divided into three groups according to preop visual acuity, stage of AMD, presence of cataract and postop refraction.

“About 90% of all patients, including those with advanced maculopathy, improved their ability to perform daily essential activities, especially near tasks,” Dr. Georgaras said.

Implanting the lens improved near vision “by several lines without affecting distance vision in the majority of patients,” Dr. Georgaras said.

“The implantation of IOLs with higher power and the creation of a myopic shift postoperatively seem to work in combination with the pseudoaccommodative effect of the ReSTOR lens as a useful and effective tool for patients with maculopathy,” Dr. Georgaras said.

He said more research is necessary to fully explain the optical principles at work and to establish the exact amount of overcorrection needed with this type of IOL to achieve the ideal magnification for low vision patients.

IntraLase improves LASIK prospects

Femtosecond laser technology improves the results of LASIK and may offer surgeons a reason to continue performing LASIK rather than adopting surface ablation procedures, according to Dr. Lindstrom.

“There are significant trends around the world away from mechanical microkeratome LASIK, and I think that these trends are going to continue. In Europe most of the surgeons are moving to PRK, while in the U.S., IntraLase seems to be the most popular alternative,” he said.

Despite the movement away from microkeratome-based LASIK, Dr. Lindstrom said LASIK, with its “fast visual recovery, minimal morbidity and easy enhancement, is still the best refractive procedure for the patient.” He said the successful results that surgeons have experienced with IntraLase flap creation could help maintain interest in LASIK and decrease the trend toward surface procedures. IntraLase flap creation has improved the visual and refractive outcomes of LASIK and appears to have the potential to eliminate some of the drawbacks of mechanical microkeratomes, he said.

“Contrast sensitivity is better, there is less induced astigmatism, less need for re-treatment and even less alteration of corneal biomechanics, which may reduce the risk of iatrogenic ectasia,” he said.

The latest iteration of the IntraLase femtosecond laser, the 60 kHz FS 60, has made the procedure “nearly as fast as it is with mechanical microkeratomes,” Dr. Lindstrom said.

Using a combination of the IntraLase and the Visx CustomVue system, Dr. Lindstrom said, he can perform bilateral LASIK “in about 10 to 12 minutes.”

Light Touch CK

The Light Touch CK system produces better outcomes than earlier versions of conductive keratoplasty for patients undergoing treatment for presbyopia, according to one user of the system.

Marguerite B. McDonald

With the Light Touch technique on the Refractec NearVision CK system, 90% of the eyes had no change in induced cylinder, compared with 71% with the conventional technique, said Marguerite McDonald, MD.

“In the FDA presbyopia study with 16 treatment spots, 59% of the patients were J1 or better,” Dr. McDonald said. “But now with only eight treatment spots, placed further away from the visual axis, 63% of patients are J1 or better. If we look at J3, it was 91% in the presbyopia study; it is 97% now. Only 6% of the eyes have 1 D increase and only 4% have more than 1 D of increase, but even those few patients with 1 D or more of induced cylinder are still seeing J1 and J2 without correction.”

Dr. McDonald said the biggest change in the updated version is “in the symmetry and magnitude of corneal compression.”

In her experience, she said, “the more the surgeon presses on the cornea at the moment the energy is delivered, the less the refractive response.”

“In the classic technique, the surgeon is pressing hard on the cornea at the moment the energy is applied, but this stretches the corneal stroma just as we are trying to contract it with heat. Consistent, light pressure, just barely making contact with the cornea is much better, allows us to get more effect with fewer spots placed further away,” she said.

Fewer treatment spots means faster visual recovery for the patient, which makes the patient happier as well, Dr. McDonald said.

IntraLase temporal hinge

A temporal hinge may be the safest and most effective option when using a femtosecond laser to create LASIK flaps, said Dmitri Azar, MD.

“The original microkeratomes were designed to create a nasal hinge. However, superior hinge rapidly gained popularity because of the less likelihood of gravitation-induced flap distortion. But the superior approach also has limitations,” Dr. Azar said. “When the flap is everted, it may rest on the upper eyelid or eyelashes, which are a potential source of epithelial scratching and infection. In addition, it has been hypothesized that the effects of a superior cut on the long ciliary nerves might have a role in the onset of dry eye after LASIK.”

Because of technical difficulty and limited availability of the option in most microkeratomes, “a temporal approach was never really considered,” Dr. Azar said. He said there are several advantages to using a temporal hinge.

“It leaves a larger stromal surface available for ablation, which produces better treatments with less chances of developing glare and halos,” he said. The surgeon can also create a larger hinge without sacrificing exposed stromal surface area, adding stability to the flap, Dr. Azar said.

“In addition, the long ciliary nerves are not affected, which lowers the chances of developing dry eye symptoms. Finally, since most trauma to the eye comes from a temporal to a nasal direction, with a temporal hinge there would be less chance of flap dislocation and tearing of the flap,” he said.

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• Michela Cimberle is an OSN Correspondent based in Treviso, Italy, who covers all aspects of ophthalmology. She focuses geographically on Europe.