october 2018 managing the unhappy premium intraocular lens...

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This continuing medical education activity is provided by VINDICO medical education This activity is supported by educational grants from Alcon Laboratories, Inc.; Bausch + Lomb; Carl Zeiss Meditec, Inc.; and J & J Vision. continued on page 3 Managing the Unhappy Premium Intraocular Lens Patient Preeya K. Gupta, MD M any patients present- ing for cataract sur- gery have a natural desire to achieve spectacle inde- pendence, which requires management not only of hy- peropia and myopia but also presbyopia and astigmatism. To help reach patient goals, a variety of pre- mium intraocular lenses (IOLs), including multifocal, extended depth of focus (EDOF), toric, and presbyopia-correcting toric IOLs have been developed. With the diversity of new technology, surgeons must understand the spe- cific vision needs of their individual patients to determine which lens is most suitable. Ongo- ing research aims to further improve tech- nology, as patient outcome expectations often exceed those possible with current IOLs. Most patients are pleased with their out- comes after cataract surgery, but some are dis- satisfied. It is critical for surgeons who offer premium IOLs to be skilled at investigating the reason for and managing patients who are unhappy with their results. Some main causes of dissatisfaction include: (1) preoperative ex- pectations were not met, (2) residual refractive error is present, (3) undiagnosed or under- treated ocular surface disease (OSD), (4) poor Astigmatism Diagnosis and Management John A. Hovanesian, MD, FACS C areful planning on how to correct astigmatism is one of the most important as- pects of preparing for refrac- tive cataract surgery. Although considerable visual detail is lost with 0.5 diopters (D) of residual cylinder error, many surgeons do not take astigmatism seriously, risking a dissatisfied patient. The 2016 Ameri- can Society of Cataract and Refractive Surgery (ASCRS) clinical survey reported that 58% of respondents believed that patients would accept at least 0.75 D of postoperative residual cylinder error. 1 Conversely, only 56% of patients with more than 0.5 D of residual error were extreme- ly happy with their surgery compared with 80% who had 0.5 D. 2 In a 6000-patient keratom- etry database, 72% had 0.5 D of astigmatism prior to cataract surgery, 3 suggesting that almost three-fourths of patients should receive a toric continued on page 6 John A. Hovanesian, MD, FACS Preeya K. Gupta, MD & 1.25 Volume 3 • Number 3 • October 2018 Accreditation Vindico Medical Education is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Credit Designation Vindico Medical Education designates this enduring material for a maximum of 1.25 AMA PRA Category 1 Credit(s) ™. Physi- cians should claim only the credit commen- surate with the extent of their participation in the activity. This enduring material is approved for 1 year from the date of original release, October 25, 2018 to October 25, 2019. How to Participate in This Activity and Obtain CME Credit To participate in this CME activity, you must read the objectives and articles, complete the CME posttest, and fill in and return the registration form and evalu- ation in their entirety. Provide only one (1) correct answer for each question. A satisfactory score is defined as answer- ing 7 of 10 posttest questions correctly. Upon receipt of the completed materials, if a satisfactory score on the posttest is achieved, Vindico Medical Education will issue an AMA PRA Category 1 Credit(s) certificate within 4 to 6 weeks. Disclosures In accordance with the Accreditation Council for Continuing Medical Education’s Standards for Commercial Support, all CME providers are required to disclose to the activity audience the relevant financial relationships of the planners, authors, and reviewers involved in the development of CME content. An individual has a relevant financial relationship if he or she has a financial relationship in any amount occurring in the past 12 months with a commercial interest whose products or services are discussed in the CME activity content over which the individual has control. Relationship information appears on this page and the next page. Editorial Board/Faculty Contributors report the following relationship(s): Nicole R. Fram, MD Consulting Fee: Alcon, Allergan, CorneaGen, Johnson & Johnson, Notal Vision, Ocular Science, Omeros, RxSight, Zeiss Speakers Bureau: Alcon, Bausch + Lomb, Johnson & Johnson, Shire, Sun Contracted Research: Alcon Ownership Interest: CorneaGen Sumit (Sam) Garg, MD Consulting Fee: Avedro, Johnson & Johnson, Kala, Katena, RVO, RxSight, Rysurg, Shire, SightLife, VisionCare, Zeiss Speakers Bureau: Johnson & Johnson, Shire Ownership Interest: Eyra, Ocutrx, RPS Preeya K. Gupta, MD Consulting Fee: Alcon, Allergan, Aurea, Bio-Tissue, Johnson & Johnson Vision, Kala, NovaBay, Ocular Science, Shire, TearLab, TearScience, Zeiss A CME Publication SPECIAL EDITION!

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Page 1: October 2018 Managing the Unhappy Premium Intraocular Lens .../media/images/education-lab/activity-images… · This continuing medical education activity is provided by VINDICO medical

This continuing medical education activity is provided by

VINDICOmedical education

This activity is supported by educational grants from Alcon Laboratories, Inc.; Bausch + Lomb; Carl Zeiss Meditec, Inc.;

and J & J Vision.

continued on page 3

Managing the Unhappy Premium Intraocular Lens PatientPreeya K. Gupta, MD

Many patients present-ing for cataract sur-

gery have a natural desire to achieve spectacle inde-pendence, which requires management not only of hy-peropia and myopia but also presbyopia and astigmatism. To help reach patient goals, a variety of pre-mium intraocular lenses (IOLs), including multifocal, extended depth of focus (EDOF), toric, and presbyopia-correcting toric IOLs have been developed. With the diversity of new technology, surgeons must understand the spe-cifi c vision needs of their individual patients to

determine which lens is most suitable. Ongo-ing research aims to further improve tech-nology, as patient outcome expectations often exceed those possible with current IOLs.

Most patients are pleased with their out-comes after cataract surgery, but some are dis-satisfi ed. It is critical for surgeons who offer premium IOLs to be skilled at investigating the reason for and managing patients who are unhappy with their results. Some main causes of dissatisfaction include: (1) preoperative ex-pectations were not met, (2) residual refractive error is present, (3) undiagnosed or under-treated ocular surface disease (OSD), (4) poor

Astigmatism Diagnosis and ManagementJohn A. Hovanesian, MD, FACS

Careful planning on how to correct astigmatism is

one of the most important as-pects of preparing for refrac-tive cataract surgery. Although considerable visual detail is lost with �0.5 diopters (D) of residual cylinder error, many surgeons do not take astigmatism seriously, risking a dissatisfi ed patient. The 2016 Ameri-can Society of Cataract and Refractive Surgery

(ASCRS) clinical survey reported that 58% of respondents believed that patients would accept at least 0.75 D of postoperative residual cylinder error.1 Conversely, only 56% of patients with more than 0.5 D of residual error were extreme-ly happy with their surgery compared with 80% who had �0.5 D.2 In a 6000-patient keratom-etry database, 72% had �0.5 D of astigmatism prior to cataract surgery,3 suggesting that almost three-fourths of patients should receive a toric

continued on page 6

John A. Hovanesian, MD,

FACS

Preeya K. Gupta, MD

&1.25

Volume 3 • Number 3 • October 2018

AccreditationVindico Medical Education is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit DesignationVindico Medical Education designates this enduring material for a maximum of 1.25 AMA PRA Category 1 Credit(s)™. Physi-cians should claim only the credit commen-surate with the extent of their participation in the activity.

This enduring material is approved for 1 year from the date of original release, October 25, 2018 to October 25, 2019.

How to Participate in This Activity and Obtain CME CreditTo participate in this CME activity, you must read the objectives and articles, complete the CME posttest, and fi ll in and return the registration form and evalu-ation in their entirety. Provide only one (1) correct answer for each question. A satisfactory score is defi ned as answer-ing 7 of 10 posttest questions correctly. Upon receipt of the completed materials, if a satisfactory score on the posttest is achieved, Vindico Medical Education will issue an AMA PRA Category 1 Credit(s) ™ certifi cate within 4 to 6 weeks.

DisclosuresIn accordance with the Accreditation Council for Continuing Medical Education’s Standards for Commercial Support, all CME providers are required to disclose to the activity audience the relevant fi nancial relationships of the planners, authors, and reviewers involved in the development of CME content. An individual has a relevant fi nancial relationship if he or she has a fi nancial relationship in any amount occurring in the past 12 months with a commercial interest whose products or services are discussed in the CME activity content over which the individual has control. Relationship information appears on this page and the next page.

Editorial Board/Faculty Contributors report the following relationship(s):

Nicole R. Fram, MDConsulting Fee: Alcon, Allergan, CorneaGen, Johnson & Johnson, Notal Vision, Ocular Science, Omeros, RxSight, ZeissSpeakers Bureau: Alcon, Bausch + Lomb, Johnson & Johnson, Shire, SunContracted Research: AlconOwnership Interest: CorneaGen

Sumit (Sam) Garg, MDConsulting Fee: Avedro, Johnson & Johnson, Kala, Katena, RVO, RxSight, Rysurg, Shire, SightLife, VisionCare, ZeissSpeakers Bureau: Johnson & Johnson, ShireOwnership Interest: Eyra, Ocutrx, RPS

Preeya K. Gupta, MDConsulting Fee: Alcon, Allergan, Aurea, Bio-Tissue, Johnson & Johnson Vision, Kala, NovaBay, Ocular Science, Shire, TearLab, TearScience, Zeiss

A CME Publication

SPECIAL EDITION!

Page 2: October 2018 Managing the Unhappy Premium Intraocular Lens .../media/images/education-lab/activity-images… · This continuing medical education activity is provided by VINDICO medical

Created and published by Vindico Medical Education, 6900 Grove Road, Building 100, Thorofare, NJ 08086-9447. Telephone: 856-994-9400; Fax: 856-384-6680. Printed in the USA. Copyright © 2018 Vindico Medical Education. All rights reserved. No part of this publication may be reproduced without written permission from the publisher. The material presented at or in any of Vindico Medical Education continuing medical education activities does not necessarily refl ect the views and opinions of Vindico Medical Education. Neither Vindico Medical Education nor the faculty endorse or recommend any techniques, commercial products, or manufacturers. The faculty/authors may discuss the use of materials and/or products that have not yet been approved by the US Food and Drug Administration. All readers and continuing education participants should verify all information before treating patients or utilizing any product.

Inside this Issue1 Managing the Unhappy

Premium Intraocular Lens Patient

Preeya K. Gupta, MD

1 Astigmatism Diagnosis and Management

John A. Hovanesian, MD, FACS

9 Phaco Advances to Ensure Consistent Patient Outcomes

David T. Vroman, MD

14 Ocular Surface Optimization for Cataract and Refractive Surgery

Terry Kim, MD

19 CME Posttest

20 CME Registration Form

Vindico Medical Education

Medical DirectorRonald A. Codario, MD, EMBA, FACP,

FNLA, RPVI, CHCP

Senior Scientifi c DirectorJennifer Frederick, PharmD, BCPS

Senior Medical EditorBetti Bandura, ELS

Senior Program ManagerKristin Riday

Chief Medical EditorTerry Kim, MD*Professor of Ophthalmology Duke University School of MedicineChief, Cornea and External Disease DivisionDirector, Refractive Surgery ServiceDuke University Eye CenterDurham, NC* Faculty Contributor also for this issue.

Editorial BoardNicole R. Fram, MDPartner, Advanced Vision CareClinical Instructor of OphthalmologyStein Eye InstituteLos Angeles, CA

Sumit (Sam) Garg, MDVice Chair of Clinical OphthalmologyMedical DirectorAssociate Professor – Corneal, Cataract, and Refractive SurgeryGavin Herbert Eye Institute, University of CaliforniaIrvine, CA

Elizabeth Yeu, MDAssistant Professor of OphthalmologyEastern Virginia Medical SchoolPartner, Virginia Eye ConsultantsCornea, Cataract, Anterior Segment, and Refractive Surgery SpecialistNorfolk, VA

Faculty ContributorsPreeya K. Gupta, MDAssociate Professor of OphthalmologyCornea, Cataract, and Refractive SurgeryDuke University Eye CenterDurham, NC

John A. Hovanesian, MD, FACS Harvard Eye AssociatesLaguna Hills, CA

David T. Vroman, MDFounding PartnerCarolina Cataract & Laser CenterLadson, SC

Reviewer:Ronald A. Codario, MD, EMBA, FACP, FNLA, RPVI, CHCP

Medical Writer:Valerie Zimmerman, PhD

Editorial Board/Faculty Contributors report the following relationship(s) (continued from cover):

John A. Hovanesian, MD, FACSRoyalty: SLACK Incorporated, TLC Laser Center

Consulting Fee: 1-800-DOCTORS, Abbott Medical Optics, AcuFocus, Aerie, Alcon, Allegro Ophthalmics, Allergan, BlephEx, EyeDetect, Glaukos, Guardion Health Sciences, IOP/Katena, Ivantis, Kala, Novartis, Ocular Therapeutix, Omeros, ReVision Optics, Sarentis Ophthalmic, Sensimed, Shire, Tear Film Innovations, TearLab, Valeant, VaracityContracted Research: Abbott Medical Optics, AcuFocus, Aerie, Alcon, Allergan, Cloudbreak Therapeutics, Cord LLC, EyeDetect, Glaukos, IngenoEye, IOP/Katena, Novartis, Ocular Therapeutix, Omeros, ReVision Optics, Shire, Tear Film Innovations, ValeantOwnership Interest: Alcon, Alicia Surgery Center, Allegro Ophthalmics, Allergan, BlephEx, EyeDetect, Glaukos, Guardion Health Sciences, Harvard Eye Associates, Harvard Hearing, IngenoEye, MDbackline, Novartis, Ocular Therapeutix, RxSight, Sarentis Ophthalmics, Sight Sciences, Tear Film InnovationsMedical Advisory Board: 1-800-DOCTORS, Abbott Medical Optics, Aerie, BlephEx, Cord LLC, EyeDetect, Glaukos, Guardion Health Sciences, IngenoEye, IOP/Katena, Ivantis, Kala, MDbackline, Ocular Therapeutix, Omeros, ReVision Optics, Shire, Sight Sciences, Tear Film Innovations, TearLab, Valeant, Veracity

Terry Kim, MDConsulting Fee: Acucela, Aerie, Alcon/Novartis, Allergan/Actavis, Avedro, Avellino Labs, Bausch + Lomb/Valeant, BlephEx, CoDa/Ocunexus Therapeutics, Kala, NovaBay, Ocular Therapeutix, Omeros, PowerVision, Presbyopia Therapies, Shire, SightLife Surgical, Simple Contacts, TearLab, TearScienceOwnership Interest: Kala, NovaBay, Ocular Therapeutix, Omeros, SightLife Surgical, Simple Contacts, TearScience

David T. Vroman, MDContracted Research: Glaukos, Johnson & Johnson, Novartis, Ocular Therapeutix

Elizabeth Yeu, MDConsulting Fee: Beaver Visitec, Kala, Lensar, Precision Lens, Sun, ZeissSpeakers Bureau: Alcon, Allergan, BioTissue, Johnson & Johnson, Ocular Therapeutix, Omeros, Shire, TearLabOwnership Interest: GlassesOff, Modernizing Medicine, Ocular ScienceAdvisory Board: Alcon, Allergan, Bausch + Lomb/Valeant, Bio-Tissue, iOptics, Johnson & Johnson, Ocular Science, Ocular Therapeutix, OCuSoft, Shire, SightLife, TearLab, TearScience, Veracity Innovations

Reviewer reports the following relationship(s):

Ronald A. Codario, MD, EMBA, FACP, FNLA, RPVI, CHCP

No relevant fi nancial relationships to disclose.

Medical Writer reports the following relationship(s):

Valerie Zimmerman, PhDNo relevant fi nancial relationships to disclose.

Vindico Medical Education staff report the following relationship(s):

No relevant fi nancial relationships to disclose.

Signed disclosures are on fi le at Vindico Medical Education, Offi ce of Medical Affairsand Compliance.

OverviewSuccessful cataract surgery involves a multifactorial process that relies on numerous interconnected assessment, planning, and execution procedures. Phacodynamics, which is the effects of the equipment used to perform a cataract procedure on the internal environment of the eye, must be thoroughly understood to maintain a stable anterior chamber and to minimize damage due to the heat produced by ultrasonic energy during phacoemulsifi cation. New technologies, such as optical coherence tomography and femtosecond (FS) laser, can be applied to several diagnostic and procedural components of the surgery. Astigmatism can now be corrected during cataract surgery, using peripheral corneal relaxing incisions or toric intraocular lens implantation. The surgeon can select from a growing range of intraocular lenses to achieve the refractive outcomes desired by the patient. In refractive surgery, FS laser is also used to correct astigmatism, and it can be employed for high-precision cutting of LASIK fl aps. New applications for FS laser, such as softening of the lens to improve accommodation, are under investigation. The educational goals of the publication series are widespread, encompassing multiple facets of cataract surgery and refractive surgery. This issue focuses on managing the unhappy premium intraocular lens patient, astigmatism diagnosis and management, phaco advances, as well as ocular surface optimization for cataract and refractive surgery patients.

Target AudienceThe intended audience for this educational series is ophthalmologists and other health care profes-sionals involved in the treatment of patients under-going cataract and/or refractive surgery.

Unlabeled and Investigational UsageThe audience is advised that this continuing medi-cal education activity may contain references to unlabeled uses of US Food and Drug Administra-tion (FDA)-approved products or to products not approved by the FDA for use in the United States. The faculty members have been made aware of their obligation to disclose such usage. All activity participants will be informed if any speakers/au-thors intend to discuss either non-FDA approved or investigational use of products/devices.

CME Questions?Contact us at [email protected] or 856-994-9400, ext. 504.

SPECIAL EDITION!

Content for this issue of the publication series was derived from a live, closed-door, expert panel discussionheld during

&

Learning Objectives for CATARACT & REFRACTIVE 360—FUNDAMENTALS, TECHNIQUES, & TECHNOLOGYUpon successful completion of this publication series, participants should be better able to:

• Review the role of phacodynamics and ultrasound in cataract surgery and how the risk of associated complications may be minimized during their use.

• Evaluate advances in presurgical/surgical diagnostics and intraoperative guidance systems and their impact on improved refractive outcomes.

• List the benefi ts and limitations of femtosecond laser in cataract surgery.• Investigate the surgical techniques necessary to optimize outcomes in

complex cases.• Review the impact on refractive outcomes of cataract surgery-induced

and preexisting astigmatism (including posterior corneal astigmatism).• Explore diagnostic and surgical techniques that can be used to correct

astigmatism before, during, and after cataract removal.

• Compare the available types of intraocular lenses and determine their infl uence on visual outcomes.

• Assess the importance of presurgical screening and discussion with the patient for intraocular lens selection to ensure patient satisfaction with outcomes.

• Summarize the need for presurgical planning prior to refractive procedures.

• Compare advanced techniques and technology for guiding refractive surgery to reduce complications and achieve better visual outcomes.

• Evaluate the evidence supporting the use of femtosecond laser in refractive surgery.

Volume 3 • Number 3 • October 2018

2018

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perceived vision quality due to IOL design or decentration, (5) posterior capsule opacifi cation, and (6) pseudo-phakic dysphotopsia.

Unmet Preoperative Expectations

Determining the patient’s needs and expectations is an important com-ponent of a cataract surgery evalua-tion. Of importance, the surgeon must determine whether the patient’s anat-omy will allow them to achieve their goals. Patient priorities for distance, intermediate, near, or combination visual acuity should be understood before surgery. Also, patient discus-sions should focus on their lifestyles. For example, visual preferences dif-fer among patients who spend most of their time reading tablet devices or viewing a computer, those who engage in crafts such as knitting, and those who are active outdoors, in-cluding driving or even piloting air-craft. Patients should be asked about the activities for which they prefer to achieve spectacle independence and those for which spectacles are accept-able. A postoperative change in needs can lead to dissatisfaction, such as a patient who did not need spectacles for reading preoperatively may be dis-satisfi ed if postoperative near vision now requires spectacles use. Acquir-ing appropriate preoperative informa-tion can be facilitated using question-naires or standard direct questions. Trial spectacle frames can be helpful to show patients their options.

Patients must have realistic expec-tations within the limits of specifi c IOLs, especially in the presbyopia category of IOLs. The advantages and disadvantages of the technology that best fi ts patient goals, including the potential for glare/halo, must be ex-plained adequately to allow the patient to make an informed IOL choice.

Presbyopia-correcting IOL selec-tion depends on near vision goals. For

patients who depend more on interme-diate vision (20-inch range), options in-clude low-add multifocal (MF), EDOF, and accommodating IOLs. Typical choices for patients who depend on near vision (16- to 18-inch range) in-clude the +3 and +3.25 diopters (D) add MFIOLs. However, not all patients are good candidates for MFIOLs, so the surgeon must know patients’ limita-tions that may preclude suitability for those lenses.

Patients with retinal pathology, in-cluding macular degeneration; glauco-ma; dry eye disease (DED); or corneal pathology, such as Salzmann nodular degeneration or anterior basement membrane dystrophy (ABMD), are suboptimal candidates for MFIOLs. Therefore, diligent preoperative as-sessments are essential, including a good retinal examination or optical coherence tomography (OCT), to identify limiting pathologies and treat those that are reversible.

When the assessments are com-pleted, the patient’s ability for realis-tic goals based on their characteristics should be evaluated. Surgeons should be straightforward, explaining which goals can and cannot be achieved, ensuring that the patient understands. Allowing a patient to undergo sur-gery with unrealistic expectations usually leads to a dissatisfi ed patient.

Residual Refractive ErrorBlurred vision is a leading cause

of dissatisfaction after premium IOL implantation. Several studies have reported a common residual refrac-tive error range of approximately -2.00 to +1.00 D.1-5 A laser vision correction procedure, either laser in situ keratomileusis (LASIK) or pho-torefractive keratectomy (PRK), can usually correct these relatively small residual errors. Approximately 85% to 95% of patients with presbyopia-correcting IOLs achieve within 0.5-D of emmetropia after LASIK or PRK enhancement.4 Those procedures are

safe and less invasive compared with an IOL exchange. In some cases, ocu-lar surface pathology can be treated simultaneously. For example, PRK and phototherapeutic keratectomy may be used to treat both the residual refractive error and ABMD.

Patients who undergo cataract sur-gery are typically older than refractive surgery patients. When addressing post-IOL implantation issues, the eye should be assessed for corneal pathol-ogy, including ABMD, Salzmann nodular degeneration, and DED. Verify that the retina is healthy by ruling out epiretinal membrane, cystoid macular edema, and age-related macular de-generation. Refractive stability must be achieved before enhancements to correct residual refractive error are performed. Some surgeons perform a YAG laser capsulotomy before pro-ceeding with laser vision correction enhancement to ensure a stable lens position and refraction.

Avoiding Residual Refractive ErrorHigh-quality preoperative biom-

etry and modern IOL formula se-lection are key to reducing residual refractive error. In most cases, pa-tients should be as close to plano as possible for MFIOL implantation. In some situations, such as when plan-ning for an EDOF IOL or low-add MFIOL, targeting -0.3 D in the non-dominant eye and plano in the domi-nant eye may be advantageous.

Recent advances in biometry in-clude swept-source OCT, which uses variable wavelength lasers to generate optical B-scans throughout the length of the eye. This noninvasive technol-ogy has several advantages over other biometric techniques, with high-speed acquisition of 2- or 3-dimensional data in milliseconds, with high lateral and axial resolution. Swept-source OCT has the increased ability to pen-etrate dense cataracts and is more ef-fective in obtaining axial length (AL) measurements in long eyes.6-8

Continued from page 1

Cataract & Refractive 360—Fundamentals, Techniques, & Technology 3

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Importance of IOL FormulasIntraocular lens formulas have

undergone several evolutions, reaching fourth-generation for-mulas that require additional data compared with previous versions.9 Subsequent formula development aimed to simplify the calculations, without compromising accuracy. Several studies have compared the accuracy of �7 formulas that in-cluded thousands of patients.10

The Barrett Universal formula was developed for all eyes, and the Hill-RBF (radial basis function), rather than being a specifi c formula, uses existing data from thousands of eyes to predict results based on the specifi c cataract surgery patient’s data. The Holladay I and II formu-las, which have been available since the 1990s, are still commonly used. Several formulas, including the Bar-rett True-K and Haigis-L formulas, have been explored in post-refrac-tive cataract surgery cases.11 The Barrett True-K formula, modeled on the Barrett Universal II formula, cal-culates a modifi ed keratometry value based on current anterior corneal power measurement values.12 The Haigis-L method is among those that do not use previous data.13

Intraocular lens formulas may not provide accurate results in eyes with long AL. Thus, the Wang–Koch modifi cation was introduced in 2011 and validated for use in eyes with AL �25 mm.14 However, a recent study of 262 eyes that compared prediction errors in subgroups based on 1-mm AL increments from 25 to �28 mm, concluded that when used with the Holladay I IOL power calculation, the Wang–Koch adjustment should be applied only when AL is �27 mm.15 Prediction errors were signifi cantly lower in unadjusted eyes with ALs between 25 and 26 mm. The authors suggested that differences in base-line clinical characteristics may have contributed to their disparate results

compared with the initial studies of the Wang–Koch modifi cation.15

For patients having toric lenses implanted, the Barrett toric formula considers posterior corneal astigma-tism, yielding signifi cantly lower lev-els of residual refractive cylinder than those commonly encountered with standard calculators.16 When intra-operative aberrometry (IA) produced dissimilar measurements to those ob-tained using an IOL toric calculator, the IA resulted in a lower median ab-solute error for residual astigmatism compared with the manufacturer’s online Barrett toric algorithm.17 Intra-operative aberrometry has also been used successfully in post-refractive eyes undergoing toric IOL implanta-tion.18 Long-term IA follow-up stud-ies of spectacle independence and visual quality of life are warranted.19

Astigmatism ManagementPatients with high astigmatism

can benefi t from an EDOF or MF toric IOL, within the limits of the maximum astigmatism that can be treated with the current lenses. Some surgeons prefer to use toric IOLs in eyes with �1.5 D with-the-rule astigmatism and �0.8 D against-the-rule astigmatism. Success depends on reliable keratometry measure-ments, which is enhanced by having consistent multiple measurements. Most presbyopia IOLs are suitable for patients with lesser astigmatism, in combination with treatment by manual or femtosecond laser limbal relaxing incisions (LRIs).

A recent meta-analysis of 13 ran-domized controlled trials that exam-ined toric IOLs in eyes with preex-isting corneal astigmatism included 707 eyes randomized to toric IOLs and 706 randomized to nontoric IOLs; 225 eyes had a relaxing incision.20 Among the participants (N=1413) in the trials reviewed, preoperative astigmatism ranged from 0.75 to 3.0 D. The meta-analysis concluded

that toric IOLs provided lower resid-ual astigmatism than nontoric IOLs.

One of the smaller studies included in that meta-analysis examined a sub-group with low (0.75 to 1.5 D) versus high (1.75 to 2.5 D) astigmatism.21 In this study (N=54 eyes), LRI and toric IOL implantation had similar effectiveness in the lower astigma-tism group. However, in eyes with higher astigmatism, toric IOL im-plantation was superior to LRI.21

Undiagnosed or Undertreated Ocular Surface Disease

Dry eye disease is signifi cantly underdiagnosed preoperatively. Up to 80% of patients presenting for cataract evaluation may have signs of DED22; however, many are not diagnosed at the time of surgical evaluation. Preoperatively, almost two-thirds of 136 patients in the Prospective Health Assessment of Cataract Patients’ Ocular Surface (PHACO) study had tear breakup time (TBUT) of �5 seconds (63%), three-fourths had positive corneal staining (77%), and one-half had positive central corneal staining.23

Several studies have shown that existing DED worsens after cataract surgery.24,25 In one study, persistent dry eye symptoms continued for at least 6 months after surgery in ap-proximately one-third of patients.26 In another study, femtosecond laser sur-gery was associated with a higher risk for postoperative DED compared with manual phacoemulsifi cation.25

Evaluating the ocular surface preoperatively is essential.27 Patient questionnaires can be benefi cial, and several are freely available.28 Not all blurry vision is due to cataract, but it can be helpful to ask patients about vision fl uctuations to identify any component of OSD that may be neg-atively contributing to vision quality.

The ocular surface clinical exami-nation should include the meibomian

4 Volume 3 • Number 3 • October 2018

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glands, assessing oil quality and fl ow.27 Lissamine green or fl uores-cein staining of the conjunctiva and cornea provide important informa-tion.29 The cornea should be assessed for punctate erosions and TBUT. If DED is identifi ed, several thera-pies are available.30 Early aggressive management is key to preparing the ocular surface for cataract surgery. Topical immunomodulators, such as cyclosporine ophthalmic emulsion and lifi tegrast ophthalmic solution, or topical steroids may be indicated. Over-the-counter tears can be thera-peutic. Meibomian gland dysfunc-tion may be treated with thermal pulsation, and punctal plugs can be effective at increasing tear volume.

Perceived Poor Vision Quality

Modern EDOF and low-add MFIOLs have considerably reduced patient dissatisfaction. However, despite adequate preoperative coun-seling and management of OSD, the postoperative visual quality of some patients does not meet their expec-tations. Options for managing sub-optimal vision quality include IOL exchange and recentration of a de-centered IOL.31

Intraocular lens exchange can be performed up to several months after surgery, using careful surgical technique to reduce complications. Intraoperative alignment is critical for achieving optimal visual quality postoperatively, and vision quality issues may be due to a decentered lens rather than the design of the lens used. Optimal centration of the lens is between the pupil center and visual axis, as determined during preopera-tive assessments.32 When the distance between the pupil center and visual axis is large, this optical compromise may be associated with halos and glare, even with proper IOL centra-tion. When a lens is decentered, it can be recentered intraoperatively after

gentle dissection of the IOL from the bag. Decentration tolerance is an ad-vantage of the new EDOF IOL.33

When visual symptoms are the result of lens misalignment with the pupil, argon laser iridoplasty can be done to improve visual function.34

Other issues, including residual re-fractive error, OSD, cystoid macular edema, and posterior capsule opaci-ties should be treated prior to per-forming iridoplasty.

Posterior Capsule Opacifi cation

Posterior capsule opacifi cation—a common cause of blurred vision and photic phenomenon—may be present in up to 50% of dissatis-fi ed MFIOL patients.31,35,36 Treatment with Nd:YAG capsulotomy is war-ranted in these patients. The timing of Nd:YAG capsulotomy is impor-tant, as performing an IOL exchange can be more technically challenging after capsulotomy.

SummaryProminent reasons for dissatis-

faction after premium IOL implan-tation include not meeting preopera-tive expectations, residual refractive error, undiagnosed or undertreated OSD, poor perceived vision quality due to IOL design or decentration, and posterior capsule opacifi cation. Surgeons should be aware of these potential issues, implementing strat-egies to avoid them and effectively manage them when they occur.

Case PresentationA 55-year-old woman was re-

ferred for blurred vision and halo/glare after cataract surgery and im-plantation of a multifocal lens in her right eye. She subsequently un-derwent LASIK enhancement, with minimal improvement. Her best-corrected visual acuity is 20/40, with manifest refraction spherical equiva-lent of -0.5 D. Investigation showed

that the lens was decentered, with peripheral rings in her central visual axis (Figure 1).

The lens was surgically reposi-tioned under topical anesthesia, which allowed the patient to fi xate on the coaxial light of the microscope. The 1-month follow-up revealed the cen-tral circle in the optic aligned with the visual axis (Figure 2). Best-corrected visual acuity was 20/20 and 20/25+ uncorrected. Manifest refraction spherical equivalent was -0.25 D.

References 1. Abdelghany A, et al. Eye Vis (Lond).

2014;1:2. doi:10.1186/s40662-014-0002-2.

2. Gundersen KG, et al. Clin Ophthal-mol. 2016;10:365-71.

3. Moshirfar M, et al. Expert Rev Oph-thalmol. 2014;9(6):529-37.

4. Sales CS, et al. J Cataract Refract Surg. 2015;41(6):1289-99.

5. Schallhorn SC, et al. Clin Ophthal-mol. 2016;10:765-76.

6. Arriola-Villalobos P, et al. Eye (Lond). 2017;31(3):437-42.

Figure 1. Decentered Intraocular Lens

Source: Preeya K. Gupta, MD.

Source: Preeya K. Gupta, MD.

Figure 2. Recentration of Intraocular Lens

Cataract & Refractive 360—Fundamentals, Techniques, & Technology 5

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7. Kunert KS, et al. J Cataract Refract Surg. 2016;42(1):76-83.

8. Srivannaboon S, et al. J Cataract Refract Surg. 2015;41(10):2224-32.

9. Kent C. http://www.reviewofophthalmology.com/article/in-search-of-the-perfect-iol-formula. Accessed June 11, 2018.

10. Melles RB, et al. Ophthalmology. 2018;125(2):169-78.

11. Abulafi a A, et al. Asia Pac J Oph-thalmol (Phila). 2017;6(4):332-8.

12. Abulafi a A, et al. J Cataract Refract Surg. 2016;42(3):363-9.

13. Haigis W. J Cataract Refract Surg. 2008;34(10):1658-63.

14. Wang L, et al. J Cataract Refract Surg. 2011;37(11):2018-27.

15. Popovic M, et al. J Cataract Refract Surg. 2018;44(1):17-22.

16. Gundersen KG, et al. Clin Ophthal-mol. 2016;10:2141-7.

17. Raimundo M, et al. Presented at: AAO 2017; November 14, 2017; New Orleans, LA. Poster # PA089.

18. Yesilirmak N, et al. J Refract Surg. 2016;32(1):69-70.

19. Drake S, et al. https://www.eyeworld.org/article-review-of--intraoperative-aberrometry-vs--standard-preoperative-biometry-and-a-toric-iol-calculator-for. Accessed June 12, 2018.

20. Kessel L, et al. Ophthalmology. 2016;123(2):275-86.

21. Liu Z, et al. Eye Sci. 2014;29(4):198-203.

22. Gupta PK, et al. J Cataract Refract Surg. 2018;44(9):1090-6.

23. Trattler WB, et al. Clin Ophthalmol. 2017;11:1423-30.

24. Miyake K, et al. Clin Ophthalmol. 2017;11:529-40.

25. Yu Y, et al. J Cataract Refract Surg. 2015;41(12):2614-23.

26. Iglesias E, et al. Cornea. 2018;37(7):893-8.

27. Wolffsohn JS, et al. Ocul Surf. 2017;15(3):539-74.

28. Hwang F. http://eyewiki.aao.org/

Dry_Eye_Syndrome_questionnaires. Accessed June 18, 2018.

29. Abelson M, et al. http://www.reviewofophthalmology.com/article/the-dye-namics-of-dry-eye-diagnosis. Accessed June 18, 2018.

30. Jones L, et al. Ocul Surf. 2017;15(3):575-628.

31. Woodward MA, et al. J Cataract Refract Surg. 2009;35(6):992-7.

32. Holladay JT. https://www.healio.com/ophthalmology/optics/news/print/ocular-surgery-news/%7B68300d9d-e1d9-4aca-b1eb-7fcf3f45248e%7D/premium-iol-centration-and-patient-suitability. Accessed June 18, 2018.

33. Yaish S, et al. J Refract Surg. 2010;26(1):71-6.

34. Solomon R, et al. J Refract Surg. 2012;28(4):281-3.

35. de Vries NE, et al. J Cataract Re-fract Surg. 2011;37(5):859-65.

36. Gibbons A, et al. Clin Ophthalmol. 2016;10:1965-70.

lens or be treated with limbal relaxing incision (LRI) for lesser astigmatism.

Ocular surface disease is a major controllable factor that contributes to residual refractive error. Optimizing the ocular surface is critical to en-able accurate astigmatism correction. Artifi cial tears and lid hygiene can be benefi cial therapies. Steroid gel or li-fi tegrast ophthalmic solution 2 times per day for 1 to 2 weeks, depending on dry eye severity, can rehabilitate the eye in preparation for biometry. Repeat topographical measurements are preferred to ensure consistent re-sults. Punctal plugs, cyclosporine, and doxycycline can be used as indicated.

Although regular astigmatism is usually corrected with a toric lens or LRI, causes of irregular astigmatism should be determined and, when ap-propriate, treated before surgery.4 In ad-dition to dry eye syndrome, pterygium, epithelial basement membrane dystro-phy, and Salzmann’s nodules are treat-able causes of irregular astigmatism.

Expanding Intraocular Lens Options

Three lenses received US Food and Drug Administration (FDA) approval in 2016 and 2017. The Symfony Toric lens, approved in July 2016, elongates the eye’s focus as a true extended depth of focus lens.5,6 It functions by manipu-lating the chromatic aberration of light coming through the lens, providing an in-focus view that is almost 1 full di-opter in range.7,8 When patients are fo-cused for distance, they also get reason-able intermediate vision. If focused for intermediate vision, they will get some near vision as well. When the extended depth of focus intraocular lens (IOL) is implanted using a mini-monovision approach, a full range of vision can be achieved7; however, more defocus and nighttime symptoms of halo may occur.

The ReSTOR 3.0 Toric IOL was FDA-approved in December 2016 and was followed by approval of the Re-STOR 2.5 Toric IOL with ActiveFocus in March 2017.9-12 The ActiveFocus

lens differs from the previous higher add ReSTOR 3.0 Toric lens, with the center optic being 100% dedicated to distance vision. In my opinion, this lens established a new benchmark for pre-serving the quality of distance vision.

Strategies to Improve Refractive Cataract Surgery OutcomesCollect Appropriate Data

Correcting astigmatism in the patient undergoing cataract surgery requires diligent preoperative assess-ment and planning. Several instru-ments for performing optical biom-etry and topography can facilitate planning astigmatism correction, and surgeons should be familiar with their features.13-15 For example, some systems may not provide adequate assessment of irregular astigma-tism, which may affect measurement results. Performing more than 1 form of keratometric assessment, including topography, is warranted.

Continued from page 1

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One study showed that 87% of eyes had “hidden” posterior corneal astig-matism that performs as an against-the-rule ([ATR] close to 180 degrees) astigmatism of approximately 0.5 D,16 which does not drift with age. There-fore, it is an element that can be as-sumed to be present and added to the preexisting topographic astigmatism. If only the anterior topographic astig-matism is corrected, with-the-rule ([WTR] close to 90 degrees) astigma-tism will be overcorrected by approxi-mately 0.5 D, and ATR astigmatism will be undercorrected by approxi-mately 0.5 D.

The typical eye undergoes a shift to ATR astigmatism of approxi-mately 0.4 D over 10 years, regard-less of cataract surgery status.17 This phenomenon leads to overcorrecting WTR and undercorrecting ATR astig-matism. Thus, for correcting WTR astigmatism, subtracting approxi-mately 0.5 D from anterior corneal measurements is warranted. When correcting steep ATR astigmatism that approaches 180 degrees, adding approximately 0.5 D to topography or keratometry results is appropriate.

Advanced Toric CalculatorsUsing an advanced toric calcula-

tor facilitates astigmatism correction. Some state-of-the-art calculators incor-porate posterior corneal astigmatism. Ideal calculators assist with creating a surgical plan from the medical record and biometry data, and archive data allow a postoperative outcome analysis for process improvement. Intraocular lens manufacturers often have online calculators specifi c for their lenses. However, surgically induced astigma-tism (SIA) must be accommodated, which is possible using an available online calculator that uses patient age, incision size, axis, prior corneal sur-gery, and pre- and postoperative kera-tometry values to predict the SIA.18 The SIA is typically �0.25 D when making a �2.4-mm incision at the limbus.

Five optical power calculation tools are available on the ASCRS website: Barrett To-ric Calculator, Post-Refractive IOL Cal-culator, Toric Results Analyzer, Barrett Rx Formula, and Hill-RBF Calculator.19,20 The Bar-rett Rx Formula (the newest addition) cal-culates IOL exchange power for piggyback or IOL exchange, assum-ing the predicted effec-tive lens position for the initial IOL was correct. The calculator predicts the spherical IOL power and the recommended toric cylinder for the exchange or piggyback, consider-ing SIA during the procedure. How-ever, SIA is not considered when per-forming a lens rotation.

The Toric Results Analyzer (https://www.astigmatismfi x.com), developed by John Berdahl, MD, and David Hardten, MD, can help assess align-ment of a previously placed toric IOL. It compares the current IOL location with the patient’s manifest refraction to determine whether IOL rotation would decrease residual astigmatism. Holladay’s Toric program and the iTrace can also identify whether or not toric rotation can be helpful.

Verify Results With AberrometryAberrometry results should be

confi rmed. Intraoperative aberrometry can provide considerable benefi t, with enhancement rate reductions of 50% or more. New surgeons should input the data themselves to become famil-iar with the instrument and the effects of input errors. Extra time to learn the controls and options is usually required beyond that provided in training ses-sions. When a trainer is making a dem-onstration, the surgeon and relevant staff, not the trainer, should control the machine and make all inputs.

During intraoperative aberrom-etry, real-time astigmatism and axis measurements are made instanta-neously (Figure 1). Observing these measurements in progress can help ensure that a consistent, good-quality reading is captured.

Obstacles to Aberrometry Accuracy

Several factors can affect intra-operative aberrometry accuracy. The positioning of the lid speculum and excessive fl uid meniscus can affect readings, as can head positioning. Ex-cessive stromal hydration should be avoided, and the intraocular pressure should be within the acceptable range. Viscoelastic on the cornea can affect readings. Intraocular lens tilt and de-centration outside of normal limits can compromise astigmatism correction.

Surgeons should remember that the cylinder correction achieved by LRI is not always immediate. For ex-ample, if an LRI was used to correct a 0.5-D WTR astigmatism, the effects may not be apparent when intraop-erative aberrometry is performed.

In addition to the lid margin and tear fi lm, which can grossly distort biometry readings, some viscoelastic products have been reported to distort aphakic refraction. A recent study in-cluded 120 eyes that had the anterior

Figure 1. Intraoperative Aberrometry: Real-time Measurements

Source: John A. Hovanesian, MD, FACS.

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chamber fi lled with 1 of 6 ophthalmic viscosurgical devices (OVD) after removal of the balanced salt solution (BSS).21 Aberrometry was performed with both BSS and OVD in the an-terior chamber, with IOL power se-lected from the reading with BSS. The clinical manifest refraction mean ab-solute error was determined 3 weeks postoperatively and compared with the extrapolated refraction if the IOL power selection had been based on the aberrometry reading under OVD. The manifest refraction mean abso-lute error determinations were statis-tically signifi cantly different between BSS and OVD for 2 of the OVDs (DisCoVisc and Amvisc Plus). There-fore, surgeons should be aware of the effects OVDs can have on the accu-racy of intraoperative aberrometry and make the appropriate adjustments.

SummaryTo achieve optimum outcomes,

astigmatism management requires thoughtful attention. Ocular sur-face disease should be managed to avoid ocular surface-induced inac-curacies. Surgeons should collect and synthesize appropriate data, using advanced tools and advanced

formulas for improved results. Intraoperative aberrometry can con-tribute to considerable outcome improvement.

Case Example: How Much Cylinder?

A 72-year-old retired engineer wants perfect vision after cataract sur-gery. In his preoperative astigmatism planning, topography was used to determine the axis of his astigmatism, and opti-cal biometry provided astigmatism magnitude. The SIA was factored

in as approximately 0.5-D fl attening at 180 degrees and 0.5-D steepening at 180 degrees, using the Baylor no-mogram to compensate for expected posterior corneal astigmatism. The fi nal biometry-based plan was +0.7 D at 100 degrees. However, intraopera-tive aberrometry indicated the eye was +2.7 D at 83 degrees (Figure 2). The speculum-secured location of the eyelid at the very edge of the cornea caused enough distortion to steepen the cornea superiorly. When the eye was opened further, and the speculum was not part of the picture, the aber-rometry reading was 0.6 D at 103 de-grees, which is closer to the original reading, supporting reliability of the biometry data.

References 1. American Society of Cataract and Re-

fractive Surgery. http://supplements.eyeworld.org/h/i/289602006-ascrs-clinical-survey-2016. Accessed June 9, 2018.

2. Hovanesian JA. Presented at: ASCRS 2015; April 17-21, 2017; San Diego, CA. Session 2-H.

3. Hill WE. https://doctor-hill.com/physicians/docs/Astigmatism.pdf. Ac-cessed June 11, 2018.

4. Devgan U. https://www.healio.

com/ophthalmology/cataract-surgery/news/print/ocular-surgery-news/%7Bb8f52847-16cd-454f-bd94-2dddebf69cd5%7D/irregular-astigmatism-should-be-addressed-in-cataract-surgical-plan. Accessed June 18, 2018.

5. Symfony [Package insert]. Santa Ana, CA: Abbott Medical Optics Inc; 2016.

6. US Food and Drug Administra-tion [Press release]. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm511446.htm. Accessed June 9, 2018.

7. Cochener B, et al. J Cataract Refract Surg. 2016;42(9):1268-75.

8. Matossian C. https://www.aao.org/current-insight/extending-capability-of-iols-extended-depth-of-foc. Ac-cessed June 9, 2018.

9. IQ ReSTOR +2.5 D [Package insert]. Fort Worth, TX: Alcon; 2015.

10. US Food and Drug Administra-tion. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?ID=397105. Accessed June 16, 2018.

11. US Food and Drug Administration https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMA/pma.cfm?id=P040020S049. Accessed June 9, 2018.

12. Pedrotti E, et al. J Refract Surg. 2014;30(11):754-60.

13. Fan R, et al. Clin Exp Ophthalmol. 2018;46(2):133-46.

14. Howes F. In: Yanoff M, Duker J, eds. Ophthalmology. 4th ed. New York, NY: Elsevier; 2014:334-42.

15. Lin HY, et al. Clin Ophthalmol. 2017;11:1291-9.

16. Koch DD, et al. J Cataract Refract Surg. 2012;38(12):2080-7.

17. Hayashi K, et al. Am J Ophthalmol. 2011;151(5):858-65.

18. Hill WE. https://sia-calculator.com/. Accessed June 9, 2018.

19. American Society of Cataract and Re-fractive Surgery. http://www.ascrs.org/online-tools. Accessed June 17, 2018.

20. Daly R. https://www.eyeworld.org/optical-power-calculation-tools-ascrs-site-expands-fi ve. Accessed June 17, 2018.

21. Masket S, et al. J Cataract Refract Surg. 2016;42(7):990-4.

Figure 2. Aberrometry Lid Margin Artifact

Biometry-based plan: +0.7@100 degrees. Ocular Response Analyzer (ORA) reading #1 (top panels), ORA reading #2 (bottom panels).Source: John A. Hovanesian, MD, FACS.

8 Volume 3 • Number 3 • October 2018

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Phaco Advances to Ensure Consistent Patient OutcomesDavid T. Vroman, MD

Phacoemulsifi-cation (phaco)

remains the gold standard for cataract surgery, and several phaco systems can provide excellent postoperative vision and low complication rates.1 Over the years, several modifi cations have incrementally improved the ef-fectiveness and safety of phaco, with specifi c machine confi gurations and capabilities that expand surgeons’ options. Technological advance-ments are continually being intro-duced, many of which can be added onto existing equipment.

Successful surgeries are performed by surgeons who are familiar with their phaco machines and have op-timized parameter settings to match their technique and skill set.2 Each

phaco machine has unique features that distinguish it from others. Maxi-mizing the machine to the individual surgeon’s incision, desired speed of movement in the eye, technique, lens density, and other unique ocular char-acteristics is critical (Table).

Common Phaco Systems in the United States

Ultrasound phaco of the crys-talline lens, using a phacoemulsi-fi er aspirator, became the preferred approach due to low complication rates and better uncorrected visual acuity outcomes compared with alternative treatment options.3 Ultrasound phaco is expected to continue to provide the standard of care into the near future, with in-creasing importance of dedicated packs and accessories that expand the capabilities of extant machines.4

The phaco process has undergone signifi cant changes since it was in-troduced 50 years ago, which has al-lowed for marked improvement in patient outcomes.5 Technological ad-vancements have also increased the safety of the procedure, including pro-tecting the posterior capsule as well as minimizing damage to the wound and endothelium. Major software and hardware improvements have become available in the past 15 years.

INFINITI Vision SystemThe INFINITI Vision System was

introduced in 2003, with improved fl uidics and a lighter handpiece compared with earlier systems.5 The OZil Intelligent Phaco technology became available in 2005, producing side-to-side oscillating motion, with thermal stress reduced when used with the Kelman tip. The Intrepid

David T. Vroman, MD

Special Situation Phacodynamic Adjustmenta Other Management Considerations

Dense cataract (black/brunescent)

Increase longitudinal phaco energy (may be tip dependent); engage intelligent phaco (lowest threshold and long burst)

Dispersive viscoelastic; reapplication of viscoelastic; use of femtosecond laser; manual SICS; miLOOP

Intraoperative fl oppy iris syndrome

Decrease fl ow and vacuum (15% reduction in AFR and vacuum); consider linear vacuum and linear fl ow to slow movement

Care with incision to prevent leak and iris prolapse; dilate with intracameral medications (epinephrine, lidocaine, NSAID); use mechanical dilation devices

Refractive lens exchange No longitudinal phaco; decreased fl ow and vacuum; consider linear AFR and vacuum

Trauma Decreased fl ow and vacuum; consider linear AFR and vacuum; decrease infusion pressure; Transformer or bimanual I/A for cortex removal; match side-port incisions to I/A size (21 vs 23 gauge)

Femtosecond laser for capsulorrhexis and lens softening; capsule stabilization system; need for alternate lens fi xation (ACIOL, iris sutured, scleral fi xed)

High myopia, post-vitrectomy Delay IOP ramp; lower infusion pressure Equilibrate anterior and posterior chamber by elevating iris; use intracameral anesthetic

Table. Phacoemulsifi cation Settings

aAdjustments to phaco settings are surgeon and equipment dependent. ACIOL = anterior chamber intraocular lens; AFR = aspiration fl ow rates; I/A = irrigation and aspiration; IOP = intraocular pressure; NSAID = nonsteroidal anti-infl ammatory drug; SICS = small-incision cataract surgery.Source: David T. Vroman, MD.

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Plus fl uidics management system uses molded fl uid paths and thick-wall polymer aspiration tubing, with increased energy effectiveness, de-creased peristaltic pulsations, and signifi cantly minimized surge.

Centurion Vision SystemThe Centurion Vision System was

introduced in 2013.5 Key features in-clude Active Fluidics technology to provide enhanced intraocular pressure (IOP) control, OZil Intelligent Phaco, the INTREPID Balanced Tip probe, and Applied Integration, with multiple cataract surgical technologies.6 The newly introduced Transformer irriga-tion/aspiration (I/A) handpiece allows for easy transition between coaxial and bimanual I/A modes.7

Active Fluidics was designed to complement smaller aspiration tub-ing and a cassette designed with low compliance to provide greater stabil-ity of IOP despite changes in fl ow and occlusion. Balanced salt solution (BSS) is actively compressed or de-compressed to maintain a stable IOP. The fl uidics management system uses dual segment technology and laser sensing of fl uid entering and leaving the eye. The system accommodates patient eye level, irrigation factor (wound size), vacuum rise time, and IOP ramp. The IOP, rather than bottle height, is set, using a conversion factor of bottle height x 0.74 as a guide to calculate IOP.

Stellaris Vision Enhancement System

The Stellaris Vision Enhancement System, with a wireless, dual-linear foot control, was launched in 2007.8 StableChamber fl uidics allows sur-geons to choose between fl ow (peri-staltic) and vacuum (Venturi) con-trol.9,10 The next-generation Stellaris Elite, with more than 1 dozen enhance-ments, received US Food and Drug Administration’s 510(k) clearance in 2017.11 One advancement, Adaptive

Fluidics, provides a responsive and controlled surgical environment by combining precise aspiration control with predictive infusion management, aiming to reduce IOP fl uctuations and post-occlusion surge. The Attune en-ergy management system uses longi-tudinal cutting to complement the new fl uidics system.

WHITESTAR Signature SystemThe WHITESTAR Signature sys-

tem, also launched in 2007, included the fi gure-8, motion–capable ELLIPS FX handpiece, an iterative improve-ment on the 2002 WHITESTAR device, which was a pulsed ultra-sonic handpiece.5 It includes both peristaltic and Venturi pump options in a single system, which is suitable for surgeons who prefer to use a peri-staltic pump to hold the nucleus dur-ing the initial chops, transitioning to a vacuum-based pump for fragment removal, cortical cleanup, and visco-surgical device removal.12 Software updates provide increased stability, with continuous IOP sampling and vacuum testing 250 times/second, anticipating pressure changes and making adjustments to maintain IOP. The user interface is intuitive, and the dual linear foot pedal is ergonomic and responsive.

Choosing Among the Options: Understanding Phaco Parameters

A basic understanding of fl uid-ics, vacuum, and power can help the surgeon make appropriate selections when planning cataract surgery. In addition, the surgeon will be better equipped to respond to any intraop-erative issues that may emerge.

Irrigation and FluidicsChamber stability depends on

maintaining a proper balance between I/A and leakage, which is the goal of intraoperative irrigation.2 Gravity fl u-idics, where a bottle of BSS is hung

above the system, uses gravity and atmospheric pressure to control IOP during surgery. Pressurization of the irrigation bottle with forced gas may also be used.

An industry-sponsored multi-center study included 100 patients having bilateral cataract surgery. The fi rst eye was randomized to the Cen-turion system with Active Fluidics or to the INFINITI system with gravity fl uidics, and the fellow eye under-going surgery within 14 days to the alternate system.13 Cumulative dissi-pated energy (CDE), aspiration fl uid volume, and aspiration time were all signifi cantly less in the Active Fluid-ics compared with the gravity fl uidics eyes (P�.001 for all comparisons).

Outcomes were reported for 412 eyes with cataract surgery per-formed by a single surgeon using the Centurion (n=207) or INFINITI (n=205) system.14 Signifi cantly less CDE was observed in the Centurion group compared with the INFINITI group in the entire cohort (P=.017), with a greater difference in the sub-group with nuclear sclerosis grade �3 (P=.01). In the entire cohort, corrected visual acuity at 1 month was similar in both groups (P=.413), whereas it was signifi cantly better in the subgroup with denser cataracts, whose surgery was performed using the Centurion system (P=.033). The 3 intraopera-tive complications—1 case of vitreous loss and 2 of iris prolapse—occurred in the Centurion group.

A prospective, nonrandomized study compared energy expenditure for conventional and femtosecond laser cataract surgery in 570 eyes us-ing the Centurion and INFINITI sys-tems.15 The mean CDE was signifi -cantly lower with the Active Fluidics system compared with the gravity fl uidics system in the femtosecond (P=.029) and conventional groups (P�.001) eyes (Figure 1). Within both fl uidics systems, the mean CDE was signifi cantly lower in the femtosecond

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than the conventional group (P�.001 for both comparisons).

PumpsPhaco pump systems include

vacuum-based Venturi and fl ow-based peristaltic pumps.2,16 In a Ven-turi system, the vacuum is always on and fl ow varies in response to vacuum pressure. There is a setting for maximum vacuum level but not for aspiration fl ow. With a bidirec-tional foot pedal, vacuum increases when the pedal is moved parallel to the fl oor (yaw) instead of perpen-dicular, allowing increased fl exibility with separate control of vacuum and ultrasound power. Pressure remains elevated at the level set by the pedal, regardless of the evacuation status. The surgeon must actively reduce the vacuum by moving the foot pedal.

In cases of phaco tip occlusion, break surge may follow vacuum re-lease if ocular fl uid rushes into the aspiration port after it is cleared of the occluded material, producing a loss of aqueous volume and concom-itant drop in IOP.2 This phenomenon can increase the risk of posterior cap-sule rupture or iris trauma. Maintain-ing a stable chamber requires an ap-propriate initial vacuum setting and skilled foot pedal control. Several in-novations, including fi lters and fl ow resistance devices in the aspiration line, as well as tubing with decreased compliance, have been introduced to reduce surge.

In a peristaltic system, where fl ow and rise time are independently con-trolled, the vacuum remains low un-less the tip becomes occluded or there is other fl ow resistance.2,3 When the tip becomes occluded with aspirated material, the vacuum increases to a preset limit, triggering vacuum pump shutoff. The vacuum will return to zero when an occlusion has been re-moved. Surge can occur in peristaltic pump systems due to stored energy in the tubing and cassette, which has

been reduced with the advent of low compliance systems.

Some surgeons appreciate having access to the features of both pumps in a single machine.17 For example, the holding power of a peristaltic pump may be preferred during lens disas-sembly, with the Venturi pump used for aspirating the pieces into the phaco tip.

An industry-sponsored laboratory study examined the occlusion break surge and vacuum rise times of the Centurion system, with Active Fluidics and 4 phacoemulsifi er aspirator sys-tems using gravity fl uidics (Centurion, INFINITI, WHITESTAR, Stellaris) under surgically relevant operating conditions.3 Several confounding vari-ables were controlled in the laboratory setting, with the same phaco handpiece, tip, and sleeve used for all systems. Oc-clusion break surge was not measured in the Stellaris system, as fl ow rate is not controlled separately from vacuum in the Venturi pump system. Both Centurion systems, with gravity and Active Fluidics, produced markedly less occlusion break surge compared with INFINITI and WHITESTAR, par-ticularly at higher vacuum pressures. WHITESTAR had a larger occlusion break surge compared with INFINITI. Vacuum rise times were similar among the peristaltic pump systems and was slowest with the Stellaris.

In an unpublished industry-sponsored laboratory study, postocclu-sion surge in the peristaltic mode was compared among the WHITESTAR Signature Pro, INFINITI, and Cen-turion. That study found less change in IOP (ie, less surge) using the WHITESTAR Signature Pro. Specifi -cally, there was 12% less change in IOP than with the Centurion and 51% less than with the INFINITI. In addi-tion, recovery to a normal IOP was more rapid with the WHITESTAR than with the other 2 systems.

Various studies have helped to identify strengths of one system over another. In clinical practice, the

surgeon’s experience with a particu-lar machine, with a complete under-standing of its strengths and weak-nesses, will provide excellent results.

Energy: Longitudinal, Torsional, and Transversal

First-generation phaco machines provided continuous, fi xed-level ul-trasound power.2 The current state-of-the-art machines allow millisecond pulse and burst control features. With the permutations available, surgeons should investigate and be familiar with power options, including pulse and burst modes, variable duty cycles, and percentage power ceilings that best support their individual surgical approach. In addition, the amplitude of longitudinal, transverse, and tor-sional tip motions can be customized.

Traditional ultrasound energy uses longitudinal back-and-forth movement to emulsify and aspirate the lens.1,2,18 The fragments are pushed away with each forward stroke, which can re-sult in decreased effi ciency and fol-lowability. In addition, longitudinal phacoemulsifi cation is a risk factor for endothelial cell loss and tissue damage. Therefore, transversal and torsional technologies were developed to in-crease ultrasound effi ciency and safety. Setting parameters for effi cient surgery requires balancing these competing

Figure 1. Cumulative Dissipated Energy

Cumulative dissipated energy (CDE) for con-ventional and femtosecond laser cataract sur-gery using 2 phacoemulsifi cation systems.Source: Data from Yesilirmak N, et al.15

Cataract & Refractive 360—Fundamentals, Techniques, & Technology 11

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forces and using them at appropri-ate times during the procedure. With transversal technology, a straight or bent phaco tip undergoes side-to-side as well as longitudinal movement. Torsional phaco provides rotary and side-to-side oscillatory movement of the bent phaco tip. The lens material is removed by surface shearing, with minimal lens material repulsion.

Intelligent phaco (IP) uses small bursts or pulses of longitudinal phaco when nearing occlusion to keep the nuclear material moving, consider-ably reducing complete occlusion and post-occlusion surge.18 The IP system allows setting the longitudinal pulse duration from 5 to 15 ms, based on lens density (Figure 2). The percent of vacuum limit at which to switch to longitudinal motion can also be set.

A recent study compared the INFINITI with IP mode with the Cen-turion without IP mode.19 No cases of complete tip obstruction in either group was noted. For 326 eyes of all nuclear grades, mean CDE was signif-icantly less with the Centurion system (P=.02) despite similar mean ultra-sound times (P=.43). Mean aspiration time was also less with the Centurion system (P=.003), with similar estimat-ed fl uid usage between the 2 systems (P=.07). All comparisons signifi cantly favored the Centurion system for 264 nuclear grade 3 eyes. These data show advantages of the Centurion sys-tem even when IP is not being used.

Several studies have compared the ultrasound technologies. Most re-ported that the torsional mode allows lens re-moval with less phaco time and energy expend-ed, as well as increased safety and reduced endo-thelial cell loss.1,20 Some surgeons prefer to use the longitudinal method in eyes with harder cata-racts, such as those with

at least a Lens Opacities Classifi cation System III (LOCS) nuclear opacifi ca-tion grade �3. A study that included 70 eyes with LOCS grade 4 or 5 com-pared biaxial small-incision torsional with IP and biaxial small-incision lon-gitudinal phaco.21 Corrected distance visual acuity, central corneal thick-ness, and endothelial cell loss were comparable between groups.

A randomized, industry-funded trial enrolled 27 patients undergoing bilateral cataract removal and multi-focal intraocular lens implantation.22 Patients were randomized to phaco with the WHITESTAR or INFINITI system for the fi rst eye, with the fel-low eye operated later, using the al-ternate system. Power settings were numerically less in the WHITESTAR group compared with the INFINITI group (45.2 vs 62.5 mJ; P=.208), effective phaco time was signifi -cantly less (-32 seconds; P=.0019), and signifi cantly less BSS was used in the WHITESTAR group (313 vs 350 mL; P=.037). Mean endothelial cell loss was signifi cantly greater at day 1 (170.7 vs 45.1; P=.02) and 1 month (382.3 vs 127.3; P=.041) in the INFINITI group compared with the WHITESTAR group and was numerically greater at week 1 (P=.17) and month 3 (P=.131). Stro-mal edema was observed on day 1 in 22% of WHITESTAR and 70% of INFINITI eyes. Pooled postop-erative central macular thickness

indicated a signifi cant difference in the WHITESTAR compared with the INFINITI group (-17.70; P=.016). Uncorrected visual acuity was similar between groups at all postoperative visits during 3 months of follow-up. The surgeon noted similar perfor-mance of the machines. However, there were no instances of tip clogging with the WHITESTAR system and 2 cases with the INFINITI system. The authors concluded that a faster and possibly more effi cient surgi-cal procedure was achieved with the transverse system compared with the torsional, with postoperative results suggesting the transverse system may be associated with improved safety.

Phaco Tips In coaxial phaco, the irrigation

sleeve is on the phaco tip, requir-ing aspiration to overcome the ir-rigation stream’s tendency to push material away from the tip.2 Chatter occurs when material bounces off the phaco tip instead of being aspirated up the tube, whereas followability is the facility by which material moves toward, is held by, and evacuated through the phaco tip.

In a study of 412 eyes that under-went cataract surgery with either the Centurion or INFINITI system, the authors suggested that part of the sig-nifi cantly reduced CDE in eyes with nuclear sclerosis �3 may have been due to the Intrepid Balanced tip used by the Centurion system compared with the mini-fl ared Kelman (MFK) tip used by the INFINITI system.14 The use of different tips was also mentioned as a likely confounding factor in a paired-eye study13 that compared the INFINITI and Centu-rion phaco machines.23 A prospective, randomized trial of 116 eyes com-pared the 45-degree MFK tip with the 45-degree Intrepid tip, using both on the INFINITI system.24 That study also noted superior outcomes with the Intrepid tip compared with the MFK.

Figure 2. Intelligent Phaco

Source: David T. Vroman, MD.

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In the entire cohort, total ultrasound time, torsional ultrasound time, CDE, and estimated fl uid use were signifi -cantly less in the balanced tip group (P�.024 for all comparisons). The differences between tips were great-est in eyes with nuclear sclerosis 4, which was responsible for the signifi -cant decrease in estimated fl uid use in the entire cohort. Another study comparing the 2 tips in manual and femtosecond laser cataract surgery reported similar CDE in nuclear sclerosis 3 lenses, with signifi cantly reduced CDE for nuclear sclerosis 4 for both manual and femtosecond la-ser procedures using the balanced tip compared with the MFK tip.25

The manufacturer recently com-pleted a 3-month, 3-group multi-center trial with 182 cataracts with LOCS 2 to 4, randomized between the Centurion system with balanced tip, Centurion system with MFK tip, and INFINITI system with MFK tip.26 Initial results revealed CDE su-periority with the Centurion system with balanced tip compared with both other groups (6.2 vs 11.6 and 11.4% seconds; P�.001). The BSS use was similar among groups.

Many surgeons begin operating bi-manually on complex cases and switch to coaxial I/A when appropriate.27 In addition, some cases benefi t from switching from coaxial to bimanual modes. The Transformer I/A handpiece (Figure 3) allows switching between bimanual and coaxial modes, which is separated with a twist and pull, and then easily snapped back together. The I/A handpiece has a polymer tip that enhances safety. Applications that can benefi t from using this handpiece include cortical cleanup, traumatic cataract, small pupils, and surgery in postoperative eyes. The Transformer handpiece can also be useful in femto-second laser cases, with easy access to the subincisional cortex.

The results of these studies ex-emplify the challenges of comparing

complex systems, even in the setting of random-ized controlled trials. Phaco tips, power set-tings, aspiration fl ow rates, vacuum settings, and bottle height/IOP settings are among the many potential con-founding variables that can compromise result interpretation and va-lidity when comparing phaco equipment.23

SummaryConsiderable advancements have

been made in phaco machines, fl uid-ics, needle design, and software over the past 15 years. Understanding and maximally utilizing the phaco equipment is essential to provide optimal surgical outcomes in all pa-tients. Continuing upgrades and ad-vancements are expected to become available as surgeons and industry work to achieve additional outcome and safety improvements in cataract surgery patients.

Case PresentationA 65-year-old man presented

who was post-vitrectomy for retinal detachment in his right eye, which had a best-corrected visual acuity of 20/100. He had a nuclear sclerotic 3+ cataract, with 2+ guttae. Axial length was 29 mm. After the vitrectomy, the patient had good vision before developing the cataract; therefore, he was presumed to have good vision potential following cata-ract removal.

Optimizing the surgery for the pa-tient using the Centurion system in-cluded extending the IOP rise time to 1.5 seconds, minimizing iris stretch and pain. The initial sculpting phase was started with 60% torsional and 30% longitudinal power due to the cataract density. Quadratic section fragment removal was completed,

using torsional with IP to prevent surge. The Transformer was used for cortex removal due to his deep ante-rior chamber, allowing the switch to bimanual I/A to facilitate removal of the subincisional cortex.

References 1. Yeu E. http://www.

touchophthalmology.com/articles/clinical-study-review-role-active-fl uidics-and-torsional-phaco-power-providing-stable-and. Accessed Au-gust 28, 2018.

2. Packer M, et al. Chapter 9. http://phaco.ascrs.org/sites/phaco.ascrs.org/fi les/textbooks/Achieving%20Excellence%20in%20Cataract%20Surgery%20-%20Introduction.pdf. Accessed August 28, 2018.

3. Sharif-Kashani P, et al. BMC Oph-thalmol. 2014;14:96-102.

4. Eyewire. https://eyewire.news/ar-ticles/ultrasonic-phaco-remains-dominant-but-new-technologies-ready-to-challenge/. Accessed June 21, 2018.

5. Hillman L. http://educationhub.eyeworld.org/sites/default/fi les/pdf-articles/EW April 2017_Phaco_Phaco fi ne-tuned through collaboration with industry.pdf. Ac-cessed June 20, 2018.

6. Alcon. https://www.alcon.com/news/media-releases/alcon-introduces-centurion-vision-system-only-intelligent-phacoemulsifi cation. Accessed June 20, 2018.

Figure 3. Transformer I/A Handpiece

I/A = irrigation and aspiration.So urce: Courtesy of Brandon D. Ayres, MD.

Due to space constraints, the remaining references can be found on page 21.

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Ocular Surface Optimization for Cataract and Refractive SurgeryTerry Kim, MD

The status of the ocular surface

can have marked effects on the suc-cess of cataract and refractive surgery. A p p r o x i m a t e l y 20% of the cataract population is likely to have pre-existing dry eye.1 Cataract surgery can induce dry eye and exacerbate preexisting dry eye in a signifi cant proportion of patients.2-5 If dry eye is not addressed both pre- and post-operatively, keratometry and intra-ocular lens (IOL) calculation can be affected, possibly causing poor outcomes unrelated to the surgery. Disruption of the ocular surface can also induce distortion that is magni-fi ed by a multifocal IOL.

Optimizing the Ocular Surface Preoperatively

Increasing knowledge of the ocu-lar surface and its pathologies allows surgeons to address issues before performing cataract surgery. When the ocular surface is optimized be-fore surgery, more reliable keratom-etry and improved IOL power calcu-lations will result, postoperative dry eye will be decreased, and faster visual recovery will be achieved, contributing to a satisfi ed patient.

Preoperative screening should be performed to identify patients with ocular surface issues, particularly because many cataract patients with dry eye are asymptomatic.4,6-10 Ques-tionnaires should be used to identify symptoms. Lid anatomy and function tests include meibomian gland evalu-ation, and assessment for blepharitis. Blink rate, tear fi lm assessment, and

tear breakup time are valuable diag-nostic tests that can be performed ef-fi ciently. Ocular surface staining can be performed with lissamine green, rose bengal, or fl uorescein. Useful point-of-care diagnostics include os-molarity, matrix metalloproteinase 9 (MMP-9), and meibography.

To maximize the ocular surface, artifi cial tears can be initiated early in the preparation stages (Figure 1).The lid margin should be evaluated, and any lid margin disease should be treated concomitantly. Nutritional supplements may be benefi cial, and topical anti-infl ammatory treatment (ie, topical cyclosporine emulsion or lifi tegrast solution, along with loteprednol) may be warranted for some eyes. Treatment for severe, re-fractory dry eye may include punctal plugs or cauterization, autologous se-rum drops, oral secretagogues or im-munosuppressive therapy, moisture chamber goggles, or tarsorrhaphy.

First, Ask the PatientSeveral questionnaires are avail-

able for screening for dry eye. The Ocular Surface Disease Index (OSDI) and SPEED (Standard Pa-tient Evaluation of Eye Dryness) questionnaires are freely available and can be used to quickly identify symptomatic patients.11-14

Tear OsmolarityMeasuring tear osmolarity has

become a valuable tool for diag-nosing dry eye; however, it does not distinguish between the types of dry eye disease (DED).15-17 Os-molarity values �290 mOsmol/L are associated with normal tears, whereas �308 mOsmol/L is con-sistent with dry eye (Figure 2). In-ter-eye and inter-testing variability �8 mOsmol/L also suggest dry eye.

When patients with DED symp-toms, such as dryness, grittiness, red-ness, and itching, have normal tear

Terry Kim, MD

Figure 1. Algorithm for Maximizing the Ocular Surface

Source: Terry Kim, MD.

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osmolarity, surgeons should prop-erly investigate and treat alternative diagnoses prior to cataract surgery. A study of 50 patients with at least 1 symptom of DED but with normal tear osmolality reported allergic con-junctivitis (24%) and anterior bleph-aritis (24%) as the most common causes of patient symptoms.18 Other diagnoses included anterior base-ment membrane dystrophy (ABMD) (12%), keratoneuralgia (12%), con-tact lens intolerance (8%), conjunc-tival chalasis (8%), computer vision syndrome (6%), and trichiasis (6%).

Matrix Metalloproteinase 9 Testing

Matrix metalloproteinase 9 has a pathogenic role in infl ammatory dis-eases, which has been shown to extend to dry eye.19 Elevated levels of MMP-9 have been detected in patients with dry eye as well as in other infl amma-tion-associated ocular surface condi-tions. As a nonspecifi c marker for dry eye, it was shown to have 85% sensi-tivity and 94% specifi city for diagno-sis. Commercial testing is indicated as positive in the presence of �40 ng/mL MMP-9. A positive MMP-9 test can be used to guide initiation of anti-infl ammatory therapy.

Dynamic Meibomian Imaging

Meibomian gland dysfunction (MGD) is the most common cause of evaporative dry eye.20,21 It is commonly characterized by terminal duct ob-struction and/or changes in gland se-cretions, resulting in a compromised tear fi lm lipid layer and increased tear evaporation. Meibomian gland struc-tural defi cits associated with MGD include gland dropout, truncation, and dilation (Figure 3). Meibomian gland imaging systems are available that can help assess the integrity of the tear fi lm and meibomian gland structure.22 A device developed for in-offi ce use can alleviate meibomian

gland obstruction in both the upper and lower eyelids by simultane-ously heating and evacu-ating the glands. Follow-ing a single 12-minute procedure, sustained improvements in meibo-mian gland function and symptoms have been re-ported for up to 3 years.23

Managing MGD and blepharitis, which previously was referred to synonymously with MGD, has implications be-yond the ocular surface.24 Bacterial colonization in the abnormal milieu associated with these conditions may increase the risk for developing endophthalmitis postoperatively.

Topography and Keratometry

Corneal topography that reveals a missing area or irregular astigmatism often indicates the presence of ocular surface abnormalities,25 and several ocular surface abnormalities can inter-fere with obtaining accurate keratom-etry readings.26,27 Astigmatism should not be treated based on manifest re-fraction, which includes both corneal and lenticular astigmatism. Kera-tometry readings should be compared from several sources, such as manual, automated, and topographical. Shift-ing irregular corneal mires detected by keratometry can indicate an unstable tear fi lm, decreasing the validity of other corneal measurements.7,27

Contact lenses (CLs) are known to produce changes in corneal topogra-phy, which could also affect biometry

measurements for IOL calculations.28 A retrospective study of 26 eyes of 13 patients compared repeat biometry measurements before and after discon-tinuing hard or soft CLs for an aver-age of 18 days (range, 9 to 30 days).29 Mean duration of CL use was 35 years (range, 14 to 55 years). More than one-half (54%) of the eyes had dry eye or punctate epitheliopathy. Astigmatism often underwent a qualitative change if not quantitative change over time, with irregular against-the-rule astig-matism noted in rigid gas permeable CL wearers. After 4 weeks without CLs, the astigmatism was more regu-lar and had become with-the-rule. Axis standard deviations decreased signifi -cantly from before (4.1 degrees) to af-ter (1.2 degrees; P�.01) the CL hiatus. Fifteen eyes with �1.0 diopters (D) of astigmatism had a mean axis mea-surement change of 6.3 degrees after the CL hiatus. Intraocular lens power selection was modifi ed in 46% of eyes after discontinuing CL use. Nine were changed by 0.5 D, and 3 by 1.0 D. When �1.0 D astigmatism was used as a cutoff for toric IOL candidacy, 3 eyes became qualifi ed and 1 was dis-qualifi ed after the CL hiatus. Toricity

Figure 2. Tear Osmolarity and Dry Eye Disease

Source: Potvin R, et al15; Starr CE16; Lemp MA, et al.17

Figure 3. Meibography

Image shows meibomian gland dropout, truncation, and dilation.Source: Terry Kim, MD.

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changed for 64% of eyes: 6 by 0.75 D of IOL cylinder and 1 by 1.50 D of IOL cylinder. These data support that patients who wear CLs frequently have DED and indicate that CL wear can affect biometry measurements as well as subsequent IOL power and toric-ity selection. For some eyes, repeating biometry measurements following a CL hiatus may improve the accuracy of IOL calculations. Contact lens hia-tus recommendations include 2 weeks for soft CLs and 3 weeks for soft toric CLs. Patients with rigid gas permeable CLs should discontinue their use for 3 weeks for each decade of wear.

Anterior Basement Membrane Dystrophy

Anterior basement membrane dys-trophy is an often ignored or under-recognized cause of irregular astigma-tism that can adversely affect biometry calculations.25,30-33 Several hypotheses have been proposed for the defective epithelial adhesion to the basement membrane, including the presence and effects of increased MMP-9 activity. Anterior basement membrane dystro-phy may be challenging to diagnose due to its variable appearance. How-ever, identifying and treating ABMD is important before cataract surgery to allow more reliable keratometry and corneal topography as well as better visual potential. Treatment commonly includes superfi cial keratectomy, fol-lowed by phototherapeutic keratecto-my in cases associated with recurrent erosion syndrome. A bandage CL can be applied afterward to let the surface re-epithelialize. Repeat keratometry and cataract surgery should be de-layed for at least 1 to 2 months after ABMD treatment.

Salzmann’s Nodular Degeneration

Salzmann’s nodular degeneration is a subepithelial disorder that can cause irregular astigmatism and may easily escape diagnosis. When it is

located on the superior cornea, it can be overlooked if the upper lid is not lifted during examination. However, even peripheral nodules can infl uence cen-tral keratometry and regularity.31 Super-fi cial keratectomy may be used to peel off the elevated nodular tissue from the corneal surface, using 0.12 forceps, leaving Bowman’s layer untouched.32,34 As with ABMD, a bandage CL can be applied after treatment and keratom-etry repeated after 1 to 2 months.

PterygiumPterygium is another condition

that is often overlooked and can have considerable impact on the central cornea, even in cases where encroachment is restricted to 1 to 2 millimeters of peripheral cornea.35,36 Corneal topography can assess the impact of pterygium on corneal astig-matism. Pterygium excision prior to cataract surgery can achieve better corneal stability and more accurate IOL power calculations. After exci-sion of the pterygium, adjunctive use of fi brin glue for conjunctival auto-graft or amniotic membrane fi xation may reduce recurrence risk.37-39

Outcomes with off-label use of fi brin-based adhesives have been stud-ied extensively for several ophthalmic applications,40 including fi xation of autologous conjunctival graft after pte-rygium surgery.41 A meta-analysis in-cluded 24 studies that compared fi brin glue with sutures for autograft fi xation in pterygium surgery.37 The recurrence rate was reduced by 65% in eyes autograft-fi xated with fi brin glue com-pared with suture graft fi xation (odds ratio [OR] 0.35; P�.001), whereas the 2 procedures had similar complica-tion rates (OR, 1.12; P=.759). Surgery time was signifi cantly reduced with fi brin glue (P�.001).

Fibrin glue has also been used successfully for amniotic membrane fi xation in pterygium surgery.42 How-ever, inconsistent recurrence rates have been reported with amniotic

membrane grafting,43,44 ranging from lower45 to higher46 recurrence com-pared with conjunctival autograft transplantation. Commercial products that were developed for ophthalmic surgery use, which may not require suturing, include cryopreserved47 and dehydrated membrane products.48

International Dry Eye WorkShop

The fi rst International Dry Eye WorkShop (DEWS), sponsored by the Tear Film and Ocular Sur-face Society, published its report in 2007.49 International members from 23 countries participated on 12 sub-committees to produce DEWS II in 2017.50 Workshop objectives in-cluded updating the defi nition, clas-sifi cation, and diagnosis of DED; critically assessing the etiology, mechanism, distribution, and impact of the disorder; and addressing its management and therapy.

The updated evidence-based defi -nition of dry eye is “…a multifactorial disease of the ocular surface char-acterized by a loss of homeostasis of the tear fi lm and accompanied by ocular symptoms, in which tear fi lm instability and hyperosmolarity, ocu-lar surface infl ammation and dam-age, and neurosensory abnormalities play etiological roles.”51 However, in describing the “Vicious Circle” of DED, DEWS II emphasizes that tear hyperosmolarity is the core mecha-nism and hallmark of the disease.52

In diagnosing DED, DEWS II fol-lows an algorithm that fi rst divides presenting patients between those with and without symptoms, with both groups investigated for signs of ocular surface disease (OSD).53 When a diagnosis of DED is made, it may be aqueous defi cient, evaporative, or mixed. Most DED is evaporative, and cases of the 2 types may begin with-out signs of the other type. However, as DED progresses, the likelihood increases that characteristics of both

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aqueous defi cient and evaporative will be present.

A DEWS II algorithm recom-mends a diagnostic test battery for patients with suspected dry eye, based on responses to triaging ques-tions and risk factor analysis that as-sist with eliminating conditions that can mimic DED.54 Screening with the Dry Eye Questionnaire 5 or OSDI questionnaire is accompanied by 1 of 3 homeostasis marker tests: tear breakup time, osmolarity, or ocular surface staining. These critical diag-nostic tests are differentiated from those that inform subtype classifi ca-tion etiologies (ie, MGD imaging, ob-servation, and expression; lipid thick-ness; tear volume tests).

Preoperative Cataract/Refractive Surgery Algorithm

The American Society of Cata-ract and Refractive Surgery (ASCRS) Cornea Clinical Committee (CCC) retooled the algorithm specifi cally for OSD as it pertains to the preoperative cataract and refractive surgery patient, refl ecting the high prevalence of often asymptomatic DED in surgery pa-tients.55 In the PHACO study, although 77% of eyes had abnormal corneal staining, only 13% of patients report-ed signifi cant symptoms.4 One study noted that overall DED prevalence was 81% in 315 cataract surgery patients preoperatively, and 59% of asymptom-atic patients had at least 1 abnormal tear test, such as high osmolarity or positive MMP-9.56 The individual signs and characteristics of DED and OSD can dramatically affect refractive preci-sion and visual outcomes, as shown in 1 study, where signifi cant variability in average keratometry readings and ante-rior corneal astigmatism was observed in hyperosmolar compared with nor-mal eyes, resulting in signifi cant differ-ences in IOL power calculations.57

The CCC agrees with the DEWS II algorithm by recommending that DED

subtype be distinguished, as treatment will be tailored accordingly.55 The main differences between the ASCRS and the DEWS II algorithms are based on the frequently asymptomatic pre-operative patients who risk subopti-mal outcomes due to ocular surface issues. Most DED questionnaires are not ideal for cataract patients, thus the CCC recommends screening all preoperative refractive patients with point-of-care DED testing, including osmolarity and MMP-9, which can be used to rule in or rule out DED or other infl ammatory OSD.

The ASCRS algorithm includes diagnosing non-DED OSD; that is, DED masqueraders.55 Some patients may have normal osmolarity, with a positive MMP-9. Allergic and infec-tious conjunctivitis should be ruled out. Subtle lumps and bumps, which may be related to conditions such as ABMD, pterygium, Salzmann’s nodular degeneration, conjunctival chalasis, and superior limbic kerato-conjunctivitis, should be differentially diagnosed and treated. Specifi c point-of-care testing such as rapid immuno-chromatographic test and tear immu-noglobulin E may be warranted.

Because visual quality testing is important for preoperative patients, it has greater emphasis in the ASCRS algorithm.55 Tests that can guide treat-ment and setting expectations include ocular scatter index, aberrometry, noninvasive tear breakup time, topog-raphy (including irregularly irregular patterns, fl uctuations between blinks, and irregularity indices), and visual acuity pre- and post-lubricant drops.

DEWS II recommends starting treatment at step 1 of a 4-step process, increasing stepwise if no improvement is noted.23 Due to the urgency to opti-mize the ocular surface, the ASCRS recommends starting at step 2 and using a multi-pronged approach that may include plugs, steroids, immu-nomodulators, and antibiotics as war-ranted.55 Procedures that may achieve

more rapid DED reversal include, as warranted, intense pulsed light, ther-mal pulsation, blepharoexfoliation, and probes. Amniotic membrane and bandage CLs may be indicated for some patients. Autologous serum should be used with caution due to an inherent contamination risk. Surgical removal of lumps and bumps should be undertaken as warranted.

Preoperative measurements and preparing the surgical plan should be performed only when the surface, tear fi lm, and objective testing are normal-ized and stable over successive vis-its.55 Patient expectations should be managed appropriately, and patients with DED must be properly educated regarding the impact of the disease on their postoperative course. They should be aware that DED will likely worsen postoperatively and should ex-pect to continue treatment for at least 3 to 6 months postoperatively. The postoperative vision of patients with DED may fl uctuate, and those with multifocal and extended depth of fo-cus IOLs may have an increased risk of glare and halos.

SummaryOcular surface disease, which re-

duces the accuracy of preoperative refractive measurements and can affect visual quality pre- and post-operatively, is present in most cata-ract patients. Existing OSD is wors-ened by cataract surgery, and many eyes develop OSD postoperatively. Meibomian gland dysfunction and blepharitis may also increase the risk of endophthalmitis. Because of the adverse effects associated with OSD, surgeons should iden-tify and address OSD and atypical corneal conditions before proceed-ing with cataract surgery. Point-of-care testing should be used in cataract patients who are at risk for DED. Updated and validated treat-ment regimens should be applied to achieve better surgical outcomes.

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Case PresentationA 62-year-old woman complained

of worsening vision, particularly when driving. Her right eye (best-corrected visual acuity [BCVA] 20/80) was more symptomatic than her left eye (BCVA 20/40). Slit-lamp examination revealed 2+ central ABMD in her right eye and trace peripheral ABMD in her left eye, with 2 to 3+ nuclear sclerotic cataracts in both eyes. Tear osmolarity was normal (right eye, 289 mOsmol/L; left eye, 280 mOsmol/L). Matrix metalloproteinase 9 was positive in both eyes. She applies aqueous tears 4 times daily.

This patient deviates from the classic dry eye scenario due to her ABMD. Topography reveals a pat-tern of irregular dropout and irregu-lar astigmatism (Figure 4).

The patient underwent superfi -cial keratectomy and phototherapeu-tic keratectomy in her right eye. Her

pretreatment IOL power calculation predicted em-metropia with an 18.0-D T4 toric IOL. Eight weeks after treatment, emmetropia was pre-dicted with a monofocal 19.5-D IOL (Figure 5).

Surgeons may be tempted to proceed with cataract surgery in asymptomatic eyes with ABMD. Although minor peripheral ABMD may not affect IOL calcula-tions, centrally located ABMD can have major effects on IOL power cal-culations and must be treated before taking preoperative measurements.

References 1. Stephenson M. http://www.

reviewofophthalmology.com/article/the-relationship-between-dry-eye-and-cataract-surgery. Ac-cessed June 18, 2018.

2. Roberts C, et al. Insight. 2007;32(1):14-21.

3. Miyake K, et al. Clin Ophthalmol. 2017;11:529-40.

4. Trattler WB, et al. Clin Ophthal-mol. 2017;11:1423-30.

5. Chuang J, et al. J Cataract Refract Surg. 2017;43(12):1596-1607.

6. Ambrosio Jr R, et al. J Refract Surg. 2008;24(4):396-407.

7. Daly R. https://www.eyeworld.org/identifying-and-treating-ocular-surface-disease-cataract-surgery. Accessed June 10, 2018.

8. Hillman L. https://www.eyeworld.org/advances-preoperative-testing-refractive-surgery. Accessed June 10, 2018.

9. Movahedan A, et al. Curr Opin Ophthalmol. 2012;23(1):68-72.

10. Vergés C. European Ophthalmic Review. 2013;71:28-30.

11. Ocular Surface Disease Index. https://static1.squarespace.com/static/51ba5346e4b09459e2a8c0aa/t/55e5e844e4b0b7789bdf80f2/1441130564021/osdi.pdf. Accessed June 11, 2018.

12. SPEED Questionnaire. https://dryeyeandmgd.com/wp-content/uploads/2017/04/Offi cial-SPEED-Questionnaire.pdf. Accessed June 20, 2018.

13. Ngo W, et al. C ornea. 2013;32(9):1204-10.

14. Schiffman RM, et al. Arch Oph-thalmol. 2000;118(5):615-21.

15. Potvin R, et al. Clin Ophthalmol. 2015;9:2039-47.

16. Starr CE. https://www.tearlab.com/resources/VARIABILITY_IS_A_HALLMARK.pdf. Accessed June 10, 2018.

Figure 4. Eye With Anterior Basement Membrane Dystrophy

Topography of the right eye with anterior basement membrane dystrophy of the patient presented. SimK = simulated keratometry. Source: Terry Kim, MD.

Figure 5. Eight Weeks After Treatment

The patient in the case presented was treated with superfi cial keratectomy and phototherapeutic keratectomy in the right eye. Tx = treatment; VA = visual acuity.Source: Terry Kim, MD.

Due to space constraints, the remaining references can be found on page 21.

18 Volume 3 • Number 3 • October 2018

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CME Posttest

CME Instructions for Claiming Credit

6. Which of the following represents the most appropriate phacodynamic adjustments for patients with high myopia, post-vitrectomy?A. Utilize longitudinal phaco, as well as increase fl ow and vacuum.B. Delay IOP ramp and lower infusion pressure.C. Decrease fl ow and vacuum, as well as consider linear vacuum

and linear fl ow to slow movement.D. Decrease fl ow and vacuum, as well as increase lower

infusion pressure.

7. Which of the following is the most appropriate phacodynamic adjustment(s) for a dense, black, brunescent cataract?A. Decrease longitudinal phaco energy, as well as engage intelligent

phaco, using the lowest threshold and short burst.B. Increase longitudinal phaco energy, as well as engage intelligent

phaco, using the lowest threshold and long burst.C. Increase longitudinal phaco energy, as well as engage intelligent

phaco, using the highest threshold and short burst.D. Decrease longitudinal phaco energy, as well as engage intelligent

phaco, using the highest threshold and long burst.

8. Approximately ___% of the cataract population is likely to have preexisting dry eye.A. 5B. 10C. 20D. 40

9. Tear osmolarity greater than ____ mOsmol/L is consistent with dry eye syndrome.A. 278B. 288C. 298D. 308

10. A 65-year-old man complained of worsening vision. His left eye (BCVA of 20/80) was more symptomatic than his right eye (BCVA 20/40). Slit-lamp examination revealed 2+ central ABMD in his left eye and trace peripheral ABMD in his right eye, with 3+ nuclear sclerotic cataracts in both eyes. Tear osmolarity was normal bilaterally, whereas matrix metalloproteinase 9 was positive in both eyes. Topography reveals a pattern of irregular dropout and irregular astigmatism. What is the most prudent way to proceed?A. Immediately proceed with left-eye cataract surgery.B. Treat ABMD in the left eye before taking preoperative measurements.C. Advise the patient that his left eye is inoperable and perform

a superfi cial keratectomy as well as a phototherapeutic keratectomy on the right eye.

D. Advise the patient that his left eye is inoperable and ask him to return for surgery on the right eye if his vision gets worse.

1. Approximately what percentage of patients with presbyopia-correcting intraocular lenses (IOLs) achieve within 0.5-diopters (D) of emmetropia after LASIK or PRK enhancement?A. 85 to 95B. 65 to 75C. 45 to 55D. 25 to 35

2. All the following statements regarding residual refractive error are true except:A. Blurred vision is a leading cause of dissatisfaction after premium

IOL implantation.B. A laser vision correction procedure, either LASIK or

photorefractive keratectomy, can usually correct relatively small residual errors.

C. When addressing post-IOL implantation issues, the eye should be assessed for corneal pathology.

D. Photorefractive keratectomy but not phototherapeutic keratectomy may be used to treat residual refractive error and anterior basement membrane dystrophy (ABMD).

3. The typical eye undergoes a shift to against-the-rule astigmatism (ATR) of approximately ___ over 10 years, regardless of cataract surgery status.A. 2B. 3C. 4D. 5

4. Which of the following statements is true regarding the instruments utilized to perform optical biometry and topography to facilitate planning astigmatism correction?A. Performing more than 1 form of keratometric assessment,

including topography, is not warranted.B. One study has shown that 99% of eyes had hidden posterior

corneal astigmatism.C. Some systems may not provide adequate assessment of

irregular astigmatism, which may affect measurement results.D. If only the anterior topographic astigmatism is corrected, ATR

astigmatism will be overcorrected by 2.0 D.

5. Which of the following represent the most appropriate intraoperative phacodynamic adjustments for fl oppy iris syndrome?A. Decrease fl ow and vacuum, as well as consider linear vacuum

and linear fl ow to slow movement.B. Utilize longitudinal phaco energy and increase fl ow and vacuum.C. Increase longitudinal phaco energy and increase linear fl ow to

rapid movement.D. Delay intraocular pressure (IOP) ramp and increase

infusion pressure.

1. Proceed to the CME Registration Form. Type or print your name, address, and date of birth in the spaces provided.

2. Answer each posttest question by entering it in the Answer Sheet space provided on the Registration Form. Be sure to retain a copy of your answers for your records.

3. Complete the evaluation portion of the CME Registra-tion Form. CME Registration Forms will be returned to you if the evaluation is not completed.

4. CME Registration Forms will not be accepted after the expiration date. Return the CME Registration Form before the test expires to:

Vindico Medical EducationPO Box 36Thorofare, NJ 08086-0036or Fax to: 856-384-6680

5. For downloadable handouts, patient education tools, and online resources, please visit:VindicoCME.com/EducationalTools

6. For a downloadable PDF copy of this CME monograph, test, and evaluation (found in the Educational Tools section of Volume 3, Number 4, November 2018), please visit:Healio.com/Ophthalmology/Education-Lab

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Cataract & Refractive 360Fundamentals, Techniques, & Technology

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Volume 3 • Number 3

CME Registration Form

Answer Sheet

1 2 3 4 5 6 7 8 9 10

Please return the CME Registration Form before the test expires to:Vindico Medical Education

PO Box 36Thorofare, NJ 08086-0036or Fax to: 856-384-6680

Questions about CME?Contact us at [email protected] or Call us at 856-994-9400 ext. 504

*Time spent on this activity: Hours Minutes (Includes reading articles and completing the learning assessment and evaluation.)This information MUST be completed in order for the quiz to be scored.

THE MONOGRAPH AND TEST EXPIRE OCTOBER 25, 2019

PRINT OR TYPE

Last Name First Name Degree

Mailing Address

City State Zip Code

Date of Birth (used for tracking credits ONLY)

Phone Number FAX Number

*E-mail Address

Activity EvaluationYour evaluation of this activity is extremely important, as it allows us to plan for future educational programs. Please take a moment to answer the following questions:

1. How many years have you been treating patients with cataract and/or refractive surgery? ❏ 1 to 9 ❏ 10 to 20 ❏ 21 to 30 ❏ More than 30 ❏ N/A

2. Approximately how many patients with cataract and/or refractive surgery do you see per month? ❏ 1 to 9 ❏ 10 to 30 ❏ 31 to 50 ❏ More than 50 ❏ N/A

3. Please rate the overall educational quality of this activity (from 1 = Poor; 5 = Excellent).❏ 1 ❏ 2 ❏ 3 ❏ 4 ❏ 5

4. Do you believe this program: Y=Yes N=No 4=N/AAchieved its identifi ed educational goals and learning objectives? Y N 4Covered content that is relevant and will be useful to your practice? Y N 4Increased your awareness of gaps in evidence-aligned care? Y N 4Advanced your knowledge of practice changes that may improve gapsin patient care within your health care system? Y N 4Will increase your competence in managing these patients? Y N 4Aspired you to engage/coordinate care within your health caresystem to improve health care delivery? Y N 4Used teaching methods and educational formats that were effective for learning? Y N 4Will improve your ability to communicate with patients/caregivers? Y N 4Provided you with resources to use in your practice and/or with your patients? Y N 4Addressed and provided strategies for overcoming barriers to optimal patient care? Y N 4*Was presented objectively and was free of commercial bias? Y N 4*If you indicated that the activity was not free of commercial bias, please provide additional comments here:

Y=Yes N=No5. Future activities concerning this subject matter are necessary. Y N

6. Approximately what percentage of the activity’s content was NEW to you? ❏ 0% ❏ 25% ❏ 50% ❏ 75% ❏ 100%

7. As the result of completing this educational activity, I plan to make the following changes to my practice: Y=Yes N=No 3=Already Do 4=N/A

Consider the role of phacodynamics and ultrasound to optimize the surgical environment in my patients. Y N 3 4Consider the impact of cataract surgery-induced and preexisting astigmatism on refractive outcomes. Y N 3 4Use the most updated diagnostic and surgical techniques to correct astigmatism during and after cataract removal. Y N 3 4Consider the characteristics of a specifi c intraocular lens and its infl uence on visual outcomes when selecting a lens for an individual patient. Y N 3 4Use presurgical planning prior to refractive procedures. Y N 3 4Function within an interprofessional team to continually assess practice patterns to ensure they align with the latest evidence-based care. Y N 3 4Other planned changes to practice (please provide below):

If you do not intend to make changes to your practice, please indicate why:

8. The following are barriers I face most often in my current practice that impact my ability to provide optimal care: Y=Yes N=No 4=N/A

Lack of applicable evidence-based guidelines for my current practice/patients Y N 4Lack of time to stay up-to-date on the latest evidence-based care Y N 4Lack of systems-based coordination of care involving an interprofessional team Y N 4Access to clinical trials Y N 4Integrating/utilizing electronic health records Y N 4Implementing value-based metrics/quality measures Y N 4Insurance/fi nancial restrictions Y N 4Lack of patient engagement Y N 4Lack of patient adherence/compliance to therapy Y N 4

9. How confi dent are you in your ability to manage your patients with cataract and/or refractive surgery?

❏ Extremely Confi dent❏ Very Confi dent❏ Somewhat Confi dent❏ Not at All Confi dent❏ Does Not Apply

10. What educational topics would be of value to you for future CME activities? Please be specifi c.

11. Please indicate your degree: ❏ MD/DO ❏ PA ❏ Other Health Care ❏ PharmD/RPh ❏ RN/BSN/MSN ❏ Industry ❏ NP ❏ PhD ❏ Other:________________________

12. Please indicate your primary specialty: ❏ General Ophthalmology ❏ Glaucoma ❏ Refractive Surgery ❏ Pharmacy ❏ Retina/Vitreous ❏ Nursing ❏ Cornea/External Disease ❏ Industry ❏ Cataract Surgery ❏ Other:_______________________________

13. Please indicate your primary professional/practice setting: ❏ Offi ce/Private Practice ❏ Hospital ❏ Research ❏ Academic ❏ Residency ❏ Fellowship ❏ Urgent Care ❏ Fed/State Govt. ❏ Pharmacy ❏ Industry ❏ Administration ❏ Other:________________________________

* Required fi eld

OFFICE USE ONLYEnduring material: Other

October 25, 2018 OSN-J555

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7. Tipperman R. Cataract & Refractive Surgery Today. 2017;February:30-31.

8. Devine TM. Cataract & Refractive Sur-gery Today. 2007;March:37-8.

9. Kent C. https://www.reviewofophthalmology.com/article/phaco-know-your-fl uidics-options. Ac-cessed June 23, 2018.

10. Khalifa Y. https://millennialeye.com/articles/2017-jul-aug/the-basics-of-phacoemulsifi cation/. Accessed June 23, 2018.

11. US Food and Drug Administration. https://www.accessdata.fda.gov/cdrh_docs/pdf16/K162342.pdf. Accessed October 2, 2018.

12. Garg S. Cataract & Refractive Surgery Today. 2017;February:28.

13. Solomon KD, et al. J Cataract Refract Surg. 2016;42(4):542-9.

14. Oh LJ, et al. Int J Ophthalmol. 2017;10(11):1698-1702.

15. Yesilirmak N, et al. J Cataract Refract Surg. 2017;43(1):16-21.

16. Arregui P. https://www.healio.com/ophthalmology/cataract-surgery/news/print/ocular-surgery-news/%7ba1d0712b-26b8-4743-a5c8-f7df7c8d149f%7d/surgeon-explains-transition-from-peri-staltic-to-venturi-phaco. Accessed June 23, 2018.

17. Murphy E. https://www.ophthalmologymanagement.com/sup-plements/2014/february-2014/the-oph-thalmic-asc/advanced-phaco-systems. Accessed June 20, 2018.

18. Atas M, et al. Int J Ophthalmol. 2014;7(5):822-7.

19. Ataka S, et al. Journal of Eye & Cata-ract Surgery. 2017;3(3):Article 34.

20. Leon P, et al. Int J Ophthalmol. 2016;9(6):890-7.

21. Gonen T, et al. J Cataract Refract Surg. 2012;38(11):1918-24.

22. Assil KK, et al. Clin Ophthalmol. 2015;9:1405-11.

23. Packard R. J Cataract Refract Surg. 2016;42(9):1391.

24. Demircan S, et al. Int J Ophthalmol. 2015;8(6):1168-72.

25. Pahlitzsch M, et al. Clin Exp Ophthal-mol. 2018;46(1):35-45.

26. ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/results/NCT02502526?term=02502526&rank=1&sect=X4301256#othr. Accessed June 20, 2018.

27. Ayres B. https://crstoday.com/wp-con-tent/uploads/sites/4/2017/08/crst0817_Alcon-Centurion_Insert.pdf. Accessed June 20, 2018.

17. Lemp MA, et al. Am J Ophthalmol. 2011;151(5):792-8.e.

18. Brissette A, et al. Presented at: 2016 Tear Film & Ocular Surface Society; September 7-10, 2016; Montpellier, France. Ocular Surface Repair and Re-generation Poster Session II.

19. Lanza NL, et al. Ocul Surf. 2016;14(2):189-95.

20. Hwang H, et al. Biomed Eng Online. 2017;16(1):135.

21. Nichols KK, et al. Invest Ophthalmol Vis Sci. 2011;52(4):1922-9.

22. Compare Meibomian Gland Im-aging Systems https://www.beye.com/compare/meibomian-gland-imaging-systems. Accessed June 19, 2018.

23. Jones L, et al. Ocul Surf. 2017;15(3):575-628.

24. Geerling G, et al. Ocul Surf. 2017;15(2):179-92.

25. Loh J. US Ophthalmic Review. 2015;8(2):92-6. doi:http://doi.org/10.17925/USOR.2015.08.02.92.

26. American Academy of Ophthalmol-ogy. https://www.aao.org/focalpointss-nippetdetail.aspx?id=3ccdfc67-db93-4396-893a-33bbbe5b4a51. Accessed June 19, 2018.

27. Daly R. https://www.eyeworld.org/article-tips-for-selecting-the-best-kera-tometry-values-for-iols. Accessed June 19, 2018.

28. Ruiz-Montenegro J, et al. Ophthalmol-ogy. 1993;199(1):128-34.

29. Meyer JJ, et al. Eye Contact Lens. 2018;44 Suppl 1:S255-8.

30. Chinn A. Optometric Education. 2018;43(2):1-13.

31. Daya S. https://theophthalmologist.com/issues/0518/not-the-usual-sus-pects/. Accessed June 19, 2018.

32. Piracha A. https://www.reviewofoph-thalmology.com/article/the-benefi ts-of-pre-treating-corneas. Accessed Au-gust 29, 2018.

33. White D. https://www.healio.com/ophthalmology/cornea-external-disease/news/print/ocular-surgery-news/%7B8317b821-b141-45d5-8b14-f1949b5fd930%7D/corneal-basement-membrane-dystrophy-dry-eye-diseases-sticky-wicket. Accessed August 29, 2018.

34. Hwang F, et al. http://eyewiki.aao.org/Salzmann_Nodular_Degeneration. Ac-cessed June 19, 2018.

35. Kamiya K, et al. Medicine (Baltimore). 2015;94(52):e2232.

36. Khan FA, et al. J Coll Physicians Surg Pak. 2014;24(6):404-7.

37. Lan A, et al. Oncotarget. 2017;8(25):41487-97.

38. Liu J, et al. Expert Rev Ophthalmol. 2010;5(5):645-61.

39. Park HC, et al. Expert Review of Oph-thalmology. 2011;6(6):631-55.

40. Hovanesian JA, et al. US Ophthalmic Review. 2007;2:42-4. doi:http://doi.org/10.17925/USOR.2007.02.00.42.

41. Wanzeler ACV, et al. Clin Ophthalmol.

2018;12:833-7.

42. Hovanesian JA, et al. J Cataract Re-fract Surg. 2017;43(3):405-19.

43. Cason J, et al. http://eyewiki.aao.org/Amniotic_Membrane_Transplant. Ac-cessed June 10, 2018.

44. Noureddin GS, et al. Clin Ophthalmol. 2016;10:705-12.

45. Pan X, et al. BMC Ophthalmol. 2018;18(1):119.

46. Luanratanakorn P, et al. Br J Ophthal-mol. 2006;90(12):1476-80.

47. AmnioGraft [Package insert]. Miami, FL: Biotissue; 2013.

48. Ambiodry2 [Package insert]. Costa Mesa, CA: OKTO Ophtho; 2006.

49. International Dry Eye WorkShop. Ocul Surf. 2007;5(2):59-200.

50. Nelson JD, et al. Ocul Surf. 2017;15(3):269-75.

51. Craig JP, et al. Ocul Surf. 2017;15(4):802-12.

52. Bron AJ, et al. Ocul Surf. 2017;15(3):438-510.

53. Craig JP, et al. Ocul Surf. 2017;15(3):276-83.

54. Wolffsohn JS, et al. Ocul Surf. 2017;15(3):539-74.

55. Kim T. Presented at: ASCRS 2018; April 13, 2018; Washington, DC. 1:20 pm, Session III.

56. Gupta PK, et al. J Cataract Refract Surg. 2018;44(9):1090-6.

57. Epitropoulos AT, et al. J Cataract Refract Surg. 2015;41(8):1672-7.

Phaco Advances to Ensure Consistent Patient OutcomesContinued from page 13

Ocular Surface Optimization for Cataract and Refractive SurgeryContinued from page 18

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