The 17th annual State Of The Art Refractive and Cataract Surgery Symposium opened its doors again on a gloriously sunny day in this year’s UK City of Culture, Hull. As always an impressive faculty of speakers with diverse specialities and a wealth of knowledge and experience in their fields attended to talk to us on a range of topics. Chaired by Milind Pande of Vision Surgery and Research Centre, Hull the speakers attended from local, UK and international centres.
The first morning session was devoted to ‘Managing Cataract in Glaucoma Patients’ and was opened by Paul Foster who discussed ‘Cataract Surgery in ACG’ and also ‘Lens Removal for Primary Prevention of Narrow Angle Glaucoma’. He talked about gaining better IOP control by taking out the lens in Primary ACG reporting that often the narrowest angles and highest IOP respond very well. This needs to be carefully weighted against the increased complication rate in these very small eyes including aqueous misdirection and iris prolapse among others. Prof Foster pointed to the EAGLE study which measured outcomes of Phaco vs PI in terms of IOP, cost and patient satisfaction. The study shows that within their inclusion criteria Phaco is cost effective (reducing the need for multiple repeat medications), patients respond very well and resultant IOP is slightly better than with PI. Sheng Lim followed on with a session on ‘MIGS and Cataract surgery’, he, like the previous speaker advocated the effectiveness of Phaco in IOP reduction due to the improved outflow facility through the trabecular meshwork. He gave us a round up of the current wide variety of devices available, their method of outflow and advice as to which patients would benefit from Phaco alone and when Phaco + MIGS would be indicated. The first session was closed by Sudipto Bhatta who talked about ‘Ab Externo Glaucoma Drainage Procedures and Cataract Surgery’. In this session guidance was given as to when you might carry out trabeculectomy, cataract surgery, use drainage devices and/or use cyclo-ablation diode laser. Again Mr Bhatta agreed that Phaco is one of the options to stabilise IOP but also that, in more advanced cases when targeting a lower IOP outcome, trabeculectomy, use of valves and/or laser ablation can follow previous Phaco and MIGS and that by staggering surgeries and allowing a period of stability between procedures risks are reduced.
The second morning session was dedicated to ‘Toric IOLs’, it was opened by Sathish Srinivasan whose task it was to explain ‘Toric IOL calculations’. Firstly he extoled the importance of multiple measurements on multiple devices, including tomography where possible, to gain accurate corneal dimensions and, the need for an accurate refraction. Different calculation methods were also discussed and delegates were encouraged not to choose fixed ratio calculation methods rather to choose formulae such as Barratt that uses ELP and takes the posterior corneal measurements into consideration. This was followed by Gerd Auffarth who, aside from giving us a brief history of Heidelburg University, talked about ‘Marking and Alignment’. He concurred with the previous speakers regarding the importance of accurate biometry and covered some of the factors that are out of our control such as the rotational stability of the implants. For marking, he outlined both manual devices like the bubble or pendulum marker and surgical guiding systems such as the Zeiss Callisto or the Alcon Verion. James Ball continued the session with an excellent lecture entitled ‘Surgical Pearls’. He discussed the benefits of toric IOLs over LRIs but also the issues in terms of cost, additional time taken and potential for error. The use of systems such as Lenstar which features the Barratt toric calculator and/or guidance systems during surgery to reduce error from data transfer was discussed and advice about incision placement and haptic position was given.
The morning was brought to a close by Milind Pande who gave a thought provoking talk about ‘When Things Don’t Go To Plan’. He talked about managing toric lens patients, being realistic about what can be achieved as any error in alignment or magnitude will have an impact on resultant visual acuity. The accuracy and repeatability of biometry was again stated and to consider all factors that can influence these such as contact lens wear, dry eye, previous corneal laser surgery and keratoconus. He suggested using a back calculator to find out what is happening with a refractive surprise before trying to fix anything, these online calculators are easily accessible and, along with refractive assessment and topography/ tomography are useful before deciding whether to proceed with any further treatment.
The afternoon session was dedicated to ‘Perfect Surgery, Unhappy Patient’ and was opened by Larry Benjamin. He talked about how patients judge success and the most common cause of dissatisfaction: positive and negative dysphotopsia. Halos and glare can be of great concern to patients as can temporal dark crescents. The advice given was that many patients will adapt given good counselling and enough time however, wavefront measures looking at high order abberations, use of aspheric IOLs and delaying YAG if there is a possibility of exchange were recommended. Next Sathish Srinivasan brought his expertise with regards to ‘Presbyopia IOLs’ where patient expectations are high. He considered the 7 ‘C’s: Cyl/refractive error, Cornea/ocular surface, CME (use of OCT), Capsule (the need to YAG even subtle PCO in multifocal implants), Clarity of vision/ photopsias, Centration and Character/personality type when selecting suitable patients. This was followed by James Ball with a contrasting talk about when patients are unhappy following LASIK and SMILE. Fortunately dissatisfaction with laser eye surgery is very rare, the causes are often residual refractive error, reduced corrected VA or dry eye syndrome. Invaluable advice about careful screening and risk management was given again repeating the need for measuring in great detail corneal strength and thickness using topography and tomography. On occasions however, patient healing or on-going pain is due to poor nerve plexus recovery or recurrent erosion which can happen even with ‘perfect’ surgery.
The final lecture session was given by Gerard Panting who gave an enlightening insight into the Medico Legal Perspective in Ophthalmology. He gave an outline as to how best to avoid legal issues by knowing the legal process, recording everything and providing supporting literature that outlines the risks, benefits and alternatives to surgery.
The day was brought to a close with a session on the faculty’s own experiences with ‘Unhappy Patients after Surgical Complications’. Despite the depth of knowledge and experience on offer from our panel, this session was evidence that things do not always go according to plan and that having management strategies in place for all eventualities is vital. Subject matter varied from suprachoroidal haemorrhage to drug toxicity leading to macula oedema, and, a patient who had every possible complication following trabeculectomy surgery.
The State Of The Art Refractive and Cataract Symposium has established itself as a forum for excellence and innovation in the field. This year’s event was as informative and entertaining as ever.
The Faculty: Gerd Auffarth, Heidelberg Germany; James Ball, Leeds; Larry Benjamin, Stoke Mandeville; Sudipto Bhatta, Hull; Paul Foster, London; Sheng Lim, London; Milind Pande, Hull; Gerard Panting, London and Sathish Srinivasan, Ayr.
Review by: Emily Proudfoot (Optometrist) Vision Surgery & Research Centre, Hull
Date: June 16th 2017
Venue: The Business School, University of Hull