Surgeon: Torsional ultrasound could be ‘new standard’ in cataract surgery

New techniques and combination surgeries were among the issues discussed at this year’s German Ophthalmic Surgeons meeting.

Takayuki Akahoshi, MD, described torsional ultrasound to attendees at the German Ophthalmic Surgeons meeting. The technique may become the ‘new standard’ in cataract surgery, he said. Image: Schultz J, OSN

NUREMBERG – Torsional ultrasound has the potential to be the “new standard” in cataract surgery, Takayuki Akahoshi, MD, said at the German Ophthalmic Surgeons meeting here. The surgical learning curve is short, and minor modifications from standard phaco are all that is needed, he said.

A lateral movement of the phaco tip produces torsional ultrasound. Traditional longitudinal ultrasound moves back and forth within the eye, whereas torsional ultrasound oscillates from side to side. Torsional ultrasound can be performed through a smaller incision with a decreased risk of wound burn, according to Dr. Akahoshi.

He described several adjustments he made to the phaco sleeve and tip to further increase aspiration time and enhance wound protection. He said he added a third hole to the side of the sleeve and was able to increase irrigation time to 120 mL per second, compared with the standard 88 mL per second in traditional ultrasound.

Alcon’s OZil handpiece has “the advantage of a torsional movement combined with the traditional longitudinal movement,” he told meeting attendees. Dr. Akahoshi said he recommends using the torsional setting for soft nucleus removal and using a combination of torsional and longitudinal movements for dense cataract removal.

Dr. Akahoshi added that he bends the tip downward to further protect the wound. “The tip [needs to be] almost parallel to the incision to prevent damage,” he said.

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

Refractive Surgery

Corneal inlay may be useful for presbyopes, surgeon says

Surgical techniques and advancing technology are helping intracorneal inlays gain acceptance as a treatment option for emmetropic presbyopes, said Richard L. Lindstrom, MD.

Richard L. Lindstrom

Dr. Lindstrom, who delivered the Innovator’s Lecture, discussed his work with a new “promising” intracorneal implant, which he said could help the almost 44 million emmetropic presbyopes in the United States.

Dr. Lindstrom presented early results on 57 eyes that had been implanted with the fenestrated Acufocus Intracorneal Inlay lens. Patients ranged in age from 45 to 60 years, and baseline mean uncorrected distance visual acuity was 20/20. Near vision at baseline was J9.

At the 9-month follow-up, results showed distance vision remained 20/20, and near vision improved to J1.

“This is pretty impressive data,” Dr. Lindstrom said.

Earlier work with fenestration technology proved unsuccessful for other applications, Dr. Lindstrom said.

“But it might be useful for emmetropes,” he said.

The Acufocus lens is an ultrathin device, about 10 µm in thickness. It is made of an opaque biocompatible polymer, Dr. Lindstrom said. It features 1.6 mm pinhole apertures “placed randomly in a way that the brain will ignore, thereby removing the risk of visual disturbance,” Dr. Lindstrom said.

After administering topical anesthesia for 5 to 10 minutes, the lens is implanted into an IntraLase pocket, he said. To date, 75 lenses have been implanted in the United States, and Dr. Lindstrom said that worldwide clinical trials are ongoing.

“The journey has been 25 years long,” he said. “But after 25 years, we are almost there.”

Surgeon: Be aware of surgeries performed by other subspecialists

Refractive surgeons should pay more attention to how their surgeries affect the work of retinal specialists, according to one surgeon.

For instance, refractive surgery can compromise the fundus view in future retinal surgery, said Klaus Lucke, MD.

“This is a complication,” he said. He said he was particularly concerned with refractive lens exchange, which he said hinders vitreoretinal surgery.

“Myopic eyes get tears and they need treatment, so we need a good fundus view,” Dr. Lucke said.

Preserving the capsular diaphragm will help reduce the risk of postoperative retinal detachments, and he requested that refractive surgeons use IOLs with narrow haptics because retinal surgeons work almost exclusively in the periphery. The capsulorrhexis must be at least 6 mm in diameter, he said.

Dr. Lucke said another potential problem is cystoid macular edema.

“Patients have it after cataract surgery, so why not after refractive lens exchange?” Dr. Lucke said.

During LASIK surgery, removing the suction ring too quickly can lead to retinal problems for the patient as well, Dr. Lucke said. For instance, during suction the eye becomes longer, and when the suction is released, the eye becomes shorter and wider. A rapid increase in the width of the eye can result in retinal detachment, he said.

“Avoid sudden decompression,” he urged.

Accommodating lenses not yet viable alternative for presbyopia

Accommodating lenses have not yet reached the point of development that multifocals have for treating presbyopia, said one surgeon.

Although there are promising lenses in development and other experimental ideas are in their infancy, Ulrich Mester, MD, said they do not yet offer a viable alternative.

“The Synchrony (Visiogen) lens has more of a chance of success,” he said.

According to Dr. Mester, the Synchrony dual optic lens is being studied in three centers to validate the theories behind the lens design.

“A 1-mm shift in this lens would produce 2.2 D of accommodation shift, where one lens would only produce 1.2 D of accommodation shift,” he said. “It’s quite an intelligent design.”

Other accommodative designs have come and gone, and highly experimental concepts are still in the developmental stage, he said.

For now, Dr. Mester said, multifocals are a “good alternative.”

The author did not discuss the FDA-approved crystalens.

Retina/Vitreous

Indications for small-gauge vitrectomy expand with experience

Applications for 23- and 25-gauge vitrectomy are continuing to expand as surgeons gain more experience, according to Claus Eckardt, MD. He said he found 23-gauge instruments to be better suited for more complicated cases and 25-gauge instruments to be helpful in easier and simple cases.

“Small instruments are quite flexible,” Dr. Eckardt said. “The flexibility is extremely annoying and the learning curve is tremendous.”

Complications such as instrument fractures, postoperative hypotony and endophthalmitis are more likely with the 25-gauge vitrectomy, which is why it should not be used in complicated cases, he explained.

Wound closure is “much better with smaller gauges,” particularly when the insertion is done at a 30· angle, he said.

“It’s a good idea to ‘pre-make’ the slit with a blade-like instrument,” Dr. Eckardt suggested. “It helps with the seal.”

Although he said that he would not prefer going much smaller than 25-gauge, he suggested that 27- and even 30-gauge instruments are possibilities in the future.

“The bottom line is the end of 20-gauge is on the horizon,” he said.

Cornea

Surgeon: ‘Sensitive hands’ needed for endokeratoplasty procedure

Descemet-stripping lamellar endokeratoplasty is a complex procedure that requires sensitive hands, one surgeon told an audience during a live surgery presentation.

Francis W. Price Jr.

Francis W. Price Jr., MD, one of the world’s leading experts in this technique, showed how to perform the surgery at a local hospital. He performed the surgery under topical anesthesia to illustrate that it can be done under these conditions.

“It is more difficult with topical anesthesia because the patient can move,” he told attendees. His technique included removal of Descemet’s membrane with the aid of trypan blue to better visualize the complete removal of the tissue.

He then removed the internal lamella from the donor cornea and folded it endothelium-on-endothelium to protect it during insertion.

The difficulty during insertion, he said, is that viscoelastic cannot be used. If the anterior chamber becomes shallow, the graft will not adhere properly inside the cornea.

“You can only work with balanced salt solution or air,” he said.

Before unfolding the graft, Dr. Price placed two sutures at opposite sides of the cornea to prevent astigmatism.

“The wound is a self-sealing wound, so the sutures are only there to prevent development of astigmatism, not to seal the wound,” he said.

He then used balanced salt solution to unfold the graft once inside the eye, a process that can be exceptionally difficult if the anterior chamber is too shallow, he said.

Air is then injected to create contact pressure and fixate the graft. Once the unfolding and fixation are complete, Dr. Price created four incisions with a diamond knife to drain the excess fluid from the cornea. Visual recovery times vary, he said.

“The more the edema, the slower the recovery,” Dr. Price said.

Less invasive alternatives to penetrating corneal grafts

Combining mitomycin-C with phototherapeutic keratectomy may work well as a less invasive alternative to penetrating corneal graft, a group of surgeons reported.

In a retrospective study, Rudolf Autrata, CSc, studied 61 eyes that underwent phototherapeutic keratectomy without mitomycin-C (MMC) and 47 eyes that underwent the same procedure with MMC. Dr. Autrata said 23 eyes were pediatric, and patients were being treated for primary or recurrent anterior corneal dystrophy to improve visual acuity and to delay or postpone corneal grafting.

After phototherapeutic keratectomy, MMC 0.02% was applied to the stroma, Dr. Autrata said in a poster presentation. Follow-up ranged from 3 to 11 years.

Patients in the group without MMC treatment improved from 6/37.5 at baseline to 6/15 at the final follow-up. Those who had MMC treatment had a visual acuity improvement from 6/41 preop to 6/9.6 at the last follow-up.

Mean time to significant recurrence was 38.4 months for the group that did not receive adjunctive MMC and 53.6 months for the group that did.

“The use of topical MMC following phototherapeutic keratectomy may be safe and effective adjunctive treatment and may be helpful in preventing recurrence of anterior corneal dystrophies,” Dr. Autrata said.

The treatment needs further follow-up because there are potential long-term adverse events, he added.

Surgeon: Implant has ‘potential’ for uveitis treatment

An implant for the treatment of uveitis that is not yet approved in Europe has potential, but surgeons should still be cautious with its use, Frank Koch, MD, said. He spoke about his experience with Bausch & Lomb’s Retisert (fluocinolone acetonide intravitreal) implant.

Dr. Koch said studies have shown that the uveitis relapse rate can be decreased and the systemic administration of immunosuppressant can be reduced after implantation of the Retisert. Topical steroid use can also be reduced, Dr. Koch said.

However, studies from the United States indicated an increased rate of glaucoma — as high as 30% — but that the causes remain unknown, he said.

To implant the Retisert, the surgeon creates a 3.5-mm incision, Dr. Koch said. He suggests anchoring a prolene suture into the incision, then pulling the implant down into the eye so the front of the implant faces the vitreous.

“You want to guarantee that the implant will not touch the lens and will not hurt the retina,” he said.

The procedure is not without a significant learning curve, Dr. Koch said. He advised surgeons to use caution when performing this type of surgery.

“The vitreous tends to want to ‘push out’ the implant,” he said. “That’s why I am critical of the procedure.”

Dr. Koch called for more studies with Retisert, saying its potential for treating uveitis has not yet been proven.

“We need more studies,” he said.

Levofloxacin effective after 5 days for conjunctivitis

Most conjunctival infections are effectively treated after a 5-day cycle of levofloxacin, according to a poster presentation.

Ariadna Gierek-Lapinska, MD, and colleagues studied 69 eyes of 69 patients with bacterial conjunctivitis who were treated with 0.5% levofloxacin. Mean patient age was 43.2 years, and the patients ranged in age from 18 to 79. Success was defined as the percentage of pathogens eradicated from the conjunctiva by day 6.

Four patients still had infections by day 6, three with Streptococcus pneumoniae and one with Haemophilus influenzae, the researchers said.

Mild adverse reactions included ocular burning (4.2%), itching (2.8%) and general discomfort (2.8%).

Glaucoma

Trabeculoplasty works best in combination surgeries

Excimer laser trabeculoplasty gives the best results when combined with other surgeries such as cataract, one glaucoma specialist said.

“Excimer laser trabeculoplasty is my favorite type of laser,” said Jens Funk, MD. “Slowly but surely, I am starting to believe in this method.”

According to Dr. Funk, 2-year follow-up in patients who had undergone the surgery showed a mean patient pressure of 21 mm Hg after surgery. Combined therapy had an 80% success rate, which was much higher when compared with treatments for high IOP alone, he said.

“Indications for combined surgery are quite generous,” Dr. Funk said.

Dr. Funk said when comparing excimer laser trabeculoplasty to argon laser or selective laser trabeculoplasty, advantages to the excimer laser treatment include that it is minimally invasive, it leaves no conjunctival scar, and it takes less than 2 minutes to perform. Other advantages include a combined laser and endoscope and a laser filter of 3 mm to 4 mm in diameter, he said.

The laser can be inserted across the anterior chamber and is placed into the iridocorneal angle where small holes are placed in the trabecular meshwork.

Retina

Rheopheresis may be useful in some patients with dry AMD

Visual acuity in some patients with dry age-related macular degeneration was “statistically significantly improved” after undergoing rheopheresis treatment, said David S. Boyer, MD. He presented final results from the Multicenter Investigation of Rheopheresis for AMD, or MIRA study.

Rheopheresis is the elimination of rheologically relevant high molecular plasma proteins from the eye, Dr. Boyer said. The treatment is approved for use in Germany and is currently being investigated there as a treatment for drusen, mild pigment distribution or initial atrophy.

Calling the study the “largest masked apheresis trial ever done,” Dr. Boyer said 121 patients, ranging in age from 50 to 85 years with a baseline visual acuity of 20/32 to 20/125, were enrolled.

After 12 months, 47% of patients in the treated group gained one line compared with 18% in the control group. Dr. Boyer said 10% of the treated group lost one line of vision compared with 24% in the control group.

“The mechanism of action is unknown, Dr. Boyer said. It may modify the diffusion characteristics of Bruchs membrane.

There was a low incidence of serious adverse events, Dr. Boyer said, with only a 1.6% dropout rate.

For more information:

• Jared Schultz is an OSN Staff Writer who covers all aspects of ophthalmology. He focuses geographically on Europe and the Asia-Pacific region.