Chicago—The 2010 Kelman Lecture was delivered by Douglas D. Koch, MD, during the “Spotlight on Cataracts” session of the annual meeting of the American Academy of Ophthalmology.

In his talk, “The Quest for the Perfect Cataract Operation,” Dr. Koch gave 10 predictions for the next decade and borrowed from the words of Charles Kelman, MD, about achieving success in the quest.

“Dr. Kelman wrote: ‘It becomes a matter of selecting the possible impossible dream . . . . Evaluating your own aspirations, not setting them too low, but rather too high, just a little too high.’

“So, as we embark on the road to the next 10 years to do great things for our patients and our profession, let us aim just a little too high,” said Dr. Koch, professor and holder of The Allen, Mosbacher, and Law Chair in Ophthalmology, Cullen Eye Institute, Baylor College of Medicine, Houston.

Dr. Koch’s list of predictions related to developments in technology and techniques along with the social, socioeconomic, and financial issues cataract surgeons will face. He forecasted that femtosecond lasers will become fully integrated into routine clinical practice and that presbyopic correction will become the norm in cataract and refractive procedures as the options continue to proliferate. As a corollary, Dr. Koch proposed that surgeons will be offering a sequential series of multiple procedures as they try to preserve and maintain vision over a patient’s lifetime.

Achieving the goal of providing better vision will require practitioners to become well versed in the optics and techniques of more approaches. Surgical outcomes will be improved by more accurate methods for IOL calculation, but there will be an increased need for better ways to assess patients preoperatively, including evaluating the optics of the eye, its anatomy, and patient expectations.

Surgeons also can expect that patients will come with substantial knowledge that they’ve gleaned from the Internet. This will create a need for developing better patient education tools to ensure that consumers have correct information and misinformation is counteracted effectively, as needed.

Financial constraints will remain an ongoing concern so that surgeons need to develop strategies to become more efficient practically and financially, particularly considering the anticipated increase in cataract procedures in the future and an impending ophthalmologist workforce shortage. In addition, ophthalmologists will need to work hard as their patients’ advocates, but be prepared for major battles.

“This is a call to action for all of us,” Dr. Koch said. “We need to enhance resident and practitioner training to meet the new technical and optical challenges, rethink ways of financing medical care, and work to promote access to new technology. Ophthalmologists need to become involved in our society and in our societies to achieve these goals.”

Chicago—The possibility of explantation must be discussed preoperatively with patients considering multifocal IOL implantation as these lenses are explanted earlier and more often than monofocal IOLs.

However, if explantation becomes necessary, many techniques have been described in the peer-reviewed literature for successfully removing these lenses, said Kerry D. Solomon, MD, clinical professor of ophthalmology, Storm Eye Institute, Medical University of South Carolina, Charleston.

In deciding how to perform the explantation, there are several factors to consider, including the status of the capsular bag. For eyes with an intact capsular bag, Dr. Solomon’s method begins by using a 30-gauge needle to break the capsular and optic adhesions before switching to a cannula to perform 360° viscodissection using a dispersive viscoelastic.

Single-piece lenses are lifted up and into the anterior chamber whereas 3-piece IOLs can be dialed out. Then, a variety of cutters are available to cut the lens so that it can be removed through a small incision.

“I prefer a dispersive viscoelastic for the viscodissection,” Dr. Solomon said. “I feel this type of product does a better job separating the anterior-posterior capsule leaflets and will go back and viscodissect again if any adhesions are noticed while lifting out the lens to avoid causing a capsular bag tear.”

Chicago—When managing a patient who is unhappy with a multifocal IOL, particular care must be taken to document clinically significant posterior capsule opacification (PCO) before performing Nd:YAG posterior capsulotomy as a strategy for resolving patient complaints, said Roger F. Steinert, MD.

“IOL exchange represents the last management option available for these patients when all else has failed, and the risk of complications will be increased if Nd:YAG laser capsulotomy has been performed,” said Dr. Steinert, Irving H. Leopold Professor and chairman, Department of Ophthalmology, Gavin Herbert Eye Institute, University of California, Irvine. “So, be very slow to open the posterior capsule.”

PCO is a potential cause in multifocal IOL patients who complain about poor clarity of distance and near vision as well as in those with bothersome halo and glare. Accurate clinical assessment of significant PCO can be done by viewing the retinal details with direct ophthalmoscopy or, in Dr. Steinert’s preference, by looking at the red reflex with the posterior capsule in the focal plane.

“If the capsule is causing optical disruption, the red reflex will be irregular,” Dr. Steinert said. “If the capsule is not a problem, no irregularities are seen on red reflex.

“Remember that with oblique slit-lamp illumination you will be seeing back-scatter, whereas the retina receives forward-scattered light,” he added.

Chicago—Because a high percent of patients with primary anterior uveitis have disease recurrences, there is a need for an explicit plan to detect and manage recurrent primary anterior uveitis, said John Kempen, MD, MPH, PhD.

Dr. Kempen and his colleagues conducted a retrospective cohort study of the time to relapse of anterior uveitis in which 102 patients were followed for 165 person-years after achieving complete remission of the uveitis. Of these, 60% were women, 78% were Caucasian, and 60% (62 patients) had a disease recurrence; about 40% had a disease recurrence within 1.5 years of remissions. The recurrence rate was 24% per person-year, said Dr. Kempen, director of the Ocular Inflammation Service, Department of Ophthalmology, Scheie Eye Institute, University of Pennsylvania School of Medicine, Philadelphia.

Gender, smoking, spondyloarthropathy, or HLA-B27 positivity were not risk factors for recurrence of uveitis, but younger age was (i.e., patients in the 18- to 35-year range). There was a 2.7-fold increased risk associated with recurrence in younger patients (95% confidence interval, 1.26 to 5.95).

“Many patients with remitted anterior uveitis who present to a tertiary care center will relapse,” Dr. Kempen said. “Younger age is associated with a higher risk of relapse. Management of patients with primary anterior uveitis should include an explicit plan for detecting and managing relapses because of the large proportion of patients with recurrences of uveitis.”

Chicago—Adherence to treatment guidelines for noninfectious uveitis is surprisingly poor, according to Quan Dong Nguyen, MD. He said that 75% of physician specialists in the United States taking part in the study were unaware of the guidelines. Of those who were aware of the guidelines, 94% adhered to them.

The current treatment recommendations are local, topical, and oral steroids in this patient population in combination with the use of immunosuppressive therapy of steroid-sparing agents, said Dr. Nguyen, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore.

However, steroids cause substantial morbidity and mortality with higher doses. Because uveitis does not resolve spontaneously, long-term treatment is required.

Dr. Nguyen found that 49% to 76% of patients were receiving oral steroids ranging from 38 to 45 mg daily over a course of 16 to 22 months. Sixty-one percent to 88% received combination therapy that consisted of oral and topical steroids, and only 12% of patients were managed with steroid-sparing agents.

“Controlling the disease is challenging,” Dr. Nguyen said. “Fifty percent of patients have uncontrolled disease, 61% to 88% are on combination therapy, 84% have ocular comorbidities, and in 97% the disease recurs.

“While corticosteroids are the mainstay of treatment, 38 to 45 mg daily is too high a dose and 16 to 22 months of treatment is too long,” Dr. Nguyen added. “With less than 12% of patients using steroid-sparing drugs, these agents are underused. The community needs to be educated with emphasis on treatment guidelines.”

Chicago—A number of procedures can be performed to treat patients with a rhegmatogenous retinal detachment, specifically: conventional scleral buckling, pneumatic retinopexy, primary vitrectomy without scleral buckling, and scleral buckling combined with vitrectomy. However, among vitreoretinal specialists, there is no clear preference for any procedure, according to Mark Blumenkranz, MD.

However, the surgical trends seem to be changing, with more surgeons tending to perform vitrectomy with or without scleral buckling. That number opting for vitrectomy has increased by 72% and scleral buckling decreased by an equivalent amount. However, the outcomes are similar among the procedures.

No current procedure is appropriate 100% of the time and the choice of surgery is case specific, said Dr. Blumenkranz, professor and chairman of ophthalmology, Stanford University School of Medicine, Stanford, CA.

Factors to consider when choosing a surgery include single-surgery success, final anatomic success, final visual acuity, cost, the frequency and severity of complications, and the patient experience.

A look at the literature on the topic is not necessarily helpful. There is uncertainty regarding the degree of correlation between the results of randomized clinical trials and actual clinical practice. Statistical treatments often are inconclusive or actually inappropriate to answer the question regarding the best surgical method. In addition, there is uncertainty as to the appropriate outcome measure, such as single-surgery success, for example, that is the best indicator of the surgical effect, he explained.

There are a few different ways to treat uncomplicated retinal detachments, but there is no consensus regarding the preferred therapy.

“Individual case selection of a surgery is critical,” Dr. Blumenkranz said. “Better novel treatment options may be developed that will eliminate the debate among the existing procedures.”

Chicago—Great demand is expected for presbyopia correction surgeries over the next 10 years, said David Harmon, president of Market Scope.

“The global presbyopia population in 2009 was about 1.8 billion individuals, 23% of the world population,” Harmon said. “This is expected to increase to 2.4 billion in 2020 to 27% of the population. In countries in which people will have sufficient means to afford presbyopic correction, this represents growth of about 52.3%.”

Between 2010 and 2020, he expects to see yearly opportunities for growth in this market, from 518,000 presbyopic correction procedures, not including monovision, to almost 4.5 million in 2020, representing growth of 24.1%. He estimated that 46% of this growth will be in the United States with implantation of multifocal and accommodating IOLs and 23% in Western Europe. The balance will be throughout the rest of the world.

“Demand for surgical correction of presbyopia is a small fraction of the potential, which is great,” Harmon said. “The demand is expected to soar in the coming years aging of the population. Growing affluence in the developing world and improved technologies that improve the attractiveness of various procedures will have an impact. Even modest marketplace penetration offers significant opportunities.”

Chicago—Analyses of data collected during the prospective, randomized, placebo-controlled Singapore 5-FU study demonstrate that performing cataract surgery in eyes that have had previous trabeculectomy negatively affects trabeculectomy function, said Rahat Husain, MBBS, Glaucoma Research Unit, Moorfields Eye Hospital, London.

Dr. Husain and colleagues performed a retrospective cohort review of data prospectively gathered in the Singapore 5-FU trial, which enrolled 243 Asian patients who underwent trabeculectomy with a standardized technique involving a limbal-based conjunctival flap and were randomly assigned to receive either 5-FU augmentation or placebo (saline) intraoperatively. During post-trabeculectomy follow-up (minimum of 3 years), 97 patients underwent cataract surgery. The median time to cataract surgery was 21 months, two cataract operations were performed within 6 months of trabeculectomy, 19 between 6 and 12 months after the filtering surgery, and the rest more than 1 year later.

Using Kaplan-Meier survival techniques to estimate the mean time to trabeculectomy failure and Cox regression to evaluate the effect of interval between the procedures on trabeculectomy failure, the analyses showed that cataract surgery after trabeculectomy significantly increased the risk of trabeculectomy failure and that the magnitude of elevated risk was greater the shorter the time between the two procedures. Hazard ratios for trabeculectomy failure were 2.73 for patients having cataract surgery within 6 months of glaucoma surgery, 1.65 for those needing lens removal with 12 months, and 1.28 for those whose cataract operation was at 2 years.

“The clinical implications of these findings are that it is preferable to perform trabeculectomy in pseudophakic patients insofar as is possible,” Dr. Husain said. “To improve the longevity of bleb survival among patients with cataract and refractory glaucoma, cataract surgery should be done first if possible and trabeculectomy delayed for at least 6 months while waiting for the postoperative flare to resolve. Or, if trabeculectomy is done first, phakic patients need to be warned they may need to delay their cataract surgery so they are aware their vision will be reduced.”

DISCLAIMER:
This information has been independently developed and provided by the editors of Ophthalmology Times. The sponsor does not endorse and is not responsible for the accuracy of the content or for practices or standards of non-sponsor sources. These articles may discuss regimens that have not been approved by the FDA. For full prescribing information including indications, contraindications, warnings, precautions, and adverse experiences please see the appropriate manufacturer's product circular.