For eyes with challenging zonules, capsules, ‘be prepared’

At the Ocular Surgery News Symposium in New York, one surgeon advised attendees to have proper equipment on hand to manage eyes prone to complications.

Priscilla E. Perry Arnold

NEW YORK — When facing cataract surgery in an eye that may present a zonular or capsular challenge, the surgeon must be vigilant, suspicious and pre-pared in advance, according to Priscilla E. Perry Arnold, MD.

Dr. Arnold said eyes with challenging capsules should be treated and coded as complicated cataracts.

“You need to prepare for them as such. Document the findings for surgical planning, equipment needs and complex coding,” Dr. Arnold said here at the Ocular Surgery News Symposium.

In preparation for these cases, Dr. Arnold said, the surgeon should be sure to have the correct anesthesia, viscoelastic and phacoemulsifier on hand. In addition, in case they are needed, iris hooks, sutures, capsular tension rings, alternative IOLs and a vitrector should be available.

She recommended that surgeons should consider using low-flow parameters rather than their usual settings, which are most likely high-flow, for such cases.

Dr. Arnold, who is an OSN Cataract Surgery Section Member, said that during these complicated cases, the surgeon should bear in mind that subsequent surgery may be needed.

“If all else fails and zonular support is nonexistent, you may need a posterior segment specialist,” she said.

Postoperatively, the surgeon should monitor patients for signs of infection and cystoid macular edema, she said.

Following are the highlights from this year’s OSN symposium. Look for expanded coverage of these topics and others in upcoming issues of OSN. Most of the items below were originally published as daily coverage from the meeting on the OSN SuperSite.

Crystalens patient selection

Potential candidates for implantation with the eyeonics crystalens are motivated and well informed and understand both the positive aspects and limitations of the lens, according to Richard L. Lindstrom, MD.

Candidates for the accommodating IOL should also have had no previous ocular surgery, including refractive procedures; potential for good visual acuity in each eye; and corneal astigmatism of 1 D or less, Dr. Lindstrom said. In U.S. clinical trials of the lens, patients had axial lengths within the range of 21.5 mm to 26.6 mm, he said.

The crystalens uses the eye’s natural focusing ability to provide a single focal point throughout a full range of “seamless” vision from far to near and all distances in between, Dr. Lindstrom said.

He said the IOL’s power is selected based on the amount of distance ametropia in the patient’s eye. The crystalens provides clear distance vision, he said, and the power changes with contraction of the ciliary muscle to bring objects at intermediate and near into focus.

Benefits of Restor

The Alcon Acrysof Restor IOL improves image quality at all distances while minimizing visual disturbances, according to a surgeon who has implanted the lens.

Robert J. Cionni, MD, told attendees about his experiences with the apodized diffractive presbyopia-correcting IOL.

The Restor has a number of “unique qualities,” Dr. Cionni said, including its apodized diffractive optic area, which features a precise reduction in diffractive step heights from the center to the periphery of the 3.6-mm-diameter central region.

The lens is inserted after routine cataract extraction, Dr. Cionni said. The lens is easier to insert than the eyeonics crystalens as there is no need to create a small capsulorrhexis, he said. There is also no need to dilate the eye preoperatively or postoperatively, he said.

Dr. Cionni said that in his clinical experience with the lens in 43 eyes, 27 (63%) achieved a postoperative uncorrected visual acuity of 20/20 or better, and 23 eyes (53%) had UCVA of better than 20/20.

Educating patients preoperatively about the visual characteristics of the Restor is important, Dr. Cionni said. Patients should be reminded that “no artificial lens will perform as well as the lenses we were born with,” he said. They should be told that reading distance with the IOL may be closer than what they are used to. Dr. Cionni recommended not telling patients that they might not have to wear spectacles postoperatively.

Charging for ‘upgrade’ to Medicare service requires caution Alan E. Reider NEW YORK — Physicians must be careful not to charge for noncovered “upgrades” to Medicare services in a way that makes it appear they are subsidizing their reimbursement for the Medicare covered service, according to Alan E. Reider, JD. Mr. Reider, who is OSN Regulatory/Legislative Affairs Section Editor, spoke at the Ocular Surgery News Symposium about the complexities involved in billing for uncovered services associated with presbyopia correction performed in conjunction with Medicare-covered cataract surgery. These issues have become important recently, Mr. Reider noted, because of the Centers for Medicare and Medicaid Services ruling in May that allowed Medicare patients to be billed separately for a portion of the cost of presbyopia-correcting IOLs and the diagnostic and surgical services required to choose and implant those lenses. He said it is vital that, in billing for noncovered presbyopia-correction services performed at the time of cataract surgery in a Medicare patient, it does not appear that the surgeon is attempting to compensate for the low reimbursement for the covered surgical service. “Physicians may take into account additional physician work and resources for inserting, fitting and visual acuity testing of presbyopia-correcting IOLs,” he said. “You know what you do [for these patients] beyond normal cataract procedures.” He said additional charges billed separately to the patient for the noncovered services must appear to be reasonable in order to avoid the risk of violating rules that limit charges for surgeons who accept Medicare assignment.

Refractive Surgery

ReZoom multifocal

The second-generation Advanced Medical Optics ReZoom multifocal IOL reduces halo effects and improves the distribution of distance and near vision power in comparison with its predecessor, according to R. Bruce Wallace III, MD.

Dr. Wallace said the lens maintains the advantages of the first-generation AMO Array multifocal; these include distance-dominant optics and functional intermediate vision. The ReZoom optic is made of acrylic material with the Optiedge design to reduce posterior capsular opacification, he said.

Adjustments to the balance of distance- and near-vision rings in the optics have served to reduce halo effects from lights at night and hasten cortical adaptation to the lenses, Dr. Wallace said.

He cited finding of a recent study by Longhena and colleagues comparing the ReZoom lens to the Array, showing that 80% of patients implanted with the ReZoom reported no glare or halo, while 40% of patients implanted with the Array reported those symptoms.

The study also found that 80% of ReZoom patients were spectacle-independent, while 60% of Array patients did not rely on glasses after surgery, he said.

According to Dr. Wallace, patient selection for the ReZoom should include individuals who have a strong desire to reduce their dependence on glasses, and they should be given a full understanding of the need to adjust to the new optical system.

“I agree it’s better for hyperopic presbyopes,” Dr. Wallace said.

LASIK after PK

LASIK offers several advantages over PRK for correcting refractive errors following penetrating keratoplasty, according to Eric D. Donnenfeld, MD.

Eric D. Donnenfeld

Speaking about excimer laser treatment of post-keratoplasty refractive errors, Dr. Donnenfeld said that more than 40,000 penetrating keratoplasty procedures are performed annually, and visual rehabilitation of the patient is often difficult because of anisometropia and astigmatism.

Only 39% to 70% of eyes after PK are within 3 D of emmetropia, he said, and mean cylinder after PK is 4 D to 5 D. While contact lenses are the standard of care, many patients following PK are contact-lens intolerant, he said.

The advantages of using LASIK instead of PRK for visual rehabilitation after PK include rapid visual rehabilitation, decreased stromal scarring, less irregular astigmatism, minimal regression and the ability to treat a greater range of refractive disorders, said Dr. Donnenfeld, who is an OSN Cornea/External Disease Section Member. In his own experience, he said, 100% of post-PK eyes were within 3 D emmetropia following LASIK.

“I haven’t had any rejections with the technique,” Dr. Donnenfeld said.

Epi-LASIK flap as bandage lens

After epi-LASIK with a mechanical microkeratome, the epithelial flap acts as a bandage contact lens and does not interfere with re-epithelialization, according to early results of an ongoing study by Kerry D. Solomon, MD, and colleagues. The flap then sloughs off between postoperative day 1 and day 3, Dr. Solomon said.

Robert H. Osher, MD, right, moderated a session on new cataract techniques and technologies. Panelists from left include Richard J. MacKool, MD, Kerry D. Solomon, MD, Eric D. Donnenfeld, MD, and Richard L. Lindstrom, MD.

Dr. Solomon presented early results of a clinical study of epi-LASIK using the surface ablation module on the Advanced Medical Optics Amadeus II microkeratome. Surgeons in the study have been performing bilateral epi-LASIK using the Amadeus II Epi-Blade plastic separator with an oscillation speed of 11,000 rpm and an advance rate of 1.5 mm/second, he said.

He reported on 61 patients who were assessed at postoperative days 1, 3 and 7 for flap and bed quality and pain level.

The general observation by study surgeons, he said, was that the epithelial flap is not viable and sloughs off between the day 1 and day 3 postop visits. But the flap acts as a bandage contact lens, and “patients are fairly comfortable with the epithelium placed back over Bowman’s,” he said.

Dr. Solomon, who is an OSN Refractive Surgery Section Member, noted that the Epi-Blade plastic separator used for surface separation with the Amadeus “is not a conventional blade.”

“It’s no different than the usual equipment,” he said. “It’s simply a different blade.”

According to Dr. Solomon, advantages of the device’s surface ablation module include “smooth Bowman’s membrane; clean, clear epithelial edges; and epi-flap integrity.”

He said an ongoing study is assessing removal of the epithelial flap after debridement with the Amadeus II Epi-Blade. Data from this study will be presented at the upcoming American Academy of Ophthalmology meeting.

Glaucoma

Skills for normal-tension glaucoma

The diagnosis and management of normal-tension glaucoma is a challenge for clinicians, requiring a thoughtful and thorough approach, according to Eve J. Higginbotham, MD. Dr. Higginbotham’s keynote address at the meeting addressed the nuances of diagnosing and treating normal-tension glaucoma.

“It’s imperative for us to keep our diagnostic skills as sharp as possible” in order to recognize normal-tension glaucoma, she said.

Eve J. Higginbotham

Dr. Higginbotham, who is an OSN Glaucoma Section Member, said a thorough medical history is needed to rule out the effects of previous corticosteroid use or trauma, among other factors. She also advised measuring corneal thickness, obtaining a diurnal IOP curve and performing blood work for patients who are suspects for normal-tension glaucoma.

Normal-tension glaucoma can be a challenge to treat, Dr. Higginbotham told attendees. One study in normal-tension glaucoma patients found that a 30% reduction in IOP might be protective of the optic nerve, she said.

There is controversy as to whether normal-tension glaucoma should be considered a separate clinical entity or a subset of primary open-angle glaucoma, Dr. Higginbotham said.

“Consider that IOP is a continuous variable, with no separation between normal and abnormal,” she said.

Targeting trabecular outflow

The next generation of IOP-lowering drugs may target different aspects of the trabecular meshwork outflow, according to Douglas J. Rhee, MD. The glaucoma specialist spoke here about the current outlook for future glaucoma medications.

“There’s a dizzying array of medications available,” he said. “But targeting outflow is next.”

Dr. Rhee explained why the next generation of IOP-lowering drugs might aim to limit resistance to aqueous outflow. He said the aqueous humor provides nutrients and removes waste from anterior segment structures, including the lens. Because of that, he said, it is more desirable to enhance outflow than to decrease inflow.

In experimental work, researchers have found that most resistance to aqueous outflow is in the juxtacanalicular zone immediately before Schlemm’s canal in the trabecular meshwork, Dr. Rhee said. Researchers are investigating targeting gene delivery to the trabecular meshwork, he said.

“The juxtacanalicular is not a static structure,” he said. “It is constantly undergoing remodeling.”

Meeting focuses on case studies, panel discussions, interactivity Richard L. Lindstrom Thomas W. Samuelson NEW YORK – The Ocular Surgery News Symposium format was modified this year to allow time for more panel discussions and clinical case presentations. Richard L. Lindstrom, MD, course director for the meeting and OSN Chief Medical Editor, commented on the changes: “We added case presentations as part of the format. We found that this seemed to be a better educational experience.” OSN Glaucoma Section Member Thomas W. Samuelson, MD, who moderated a session on glaucoma surgery, asked the audience if they liked the format change to didactic sessions and panel discussions. Nearly all those in attendance raised their hands to indicate that they did. Image: Archer ME, OSN

Retina

‘PDT-plus’ for all AMD lesions

A combination of photodynamic therapy with intravitreal triamcinolone is showing efficacy in the management of all subtypes of age-related macular degeneration, according to Jay S. Duker, MD.

Jay S. Duker

Dr. Duker discussed early results with the off-label combination of therapies, dubbed “PDT-plus.” He said the technique consists of photodynamic therapy using Visudyne (verteporfin for injection, Novartis/QLT) followed immediately by an intravitreal injection of 4 mg of Kenalog (triamcinolone acetate, Bristol-Myers Squibb).

Dr. Duker noted that, despite the absence of data from randomized controlled trials, this technique is already widely performed in the United States, with nearly 50% of PDT treatments employing the combination.

In a 1-year, prospective, nonrandomized study published this year in Ophthalmology by Spaide et al, no significant side effects were noted in two groups of patients treated with PDT-plus, Dr. Duker said.

In one group in the study, patients who had never received PDT were immediately treated with the combination. In a second group, patients who had received PDT alone previously were treated with PDT-plus in the trial.

Dr. Duker, who is an OSN Retina Section Member, said the never-before-treated group “gained about 2 lines” of visual acuity.

“Those who had received PDT in the past gained 0.4 lines,” he said.

In both groups, 1.2 treatments per eye were administered in the 1-year period.

Dr. Duker stressed that no conclusions can yet be made regarding efficacy or long-term safety of PDT plus, but he said that randomized trials are under way.