One of the sessions during ASCRS Refractive Day on Friday, April 25, took a look at pearls from some of the pioneers of refractive surgery. One of the moderators, Daniel Chang, MD, said these pioneers were given leeway to share pearls on a refractive topic of their choosing.
Here’s a recap of a few presentations from this session.
Source: ASCRS
‘My Surgical Technique in Nanophthalmos’
Roberto Zaldivar, MD, provided a new approach for conducting phaco cataract surgery in a patient with nanophthalmos. These are very difficult and complicated cataract surgeries, he said. In fact, patients with an axial length of less than 19.0 mm are 21x more likely to experience a complication, such as glaucoma/IOP rise, issues with IOL calculation accuracy, posterior synechiae or peripheral anterior synechiae, corneal endothelial loss, zonular weakness, diabetic retinopathy, uveal effusion, and malignant glaucoma.
Dr. Zaldivar’s new approach to these cases is focused on one principle: avoid hydration of the vitreous body during surgery.
The keys for success in these small eyes that Dr. Zaldivar offered include using mannitol and pre-surgical acetazolamide; using physiologic IOP (20 mm Hg) during surgery; using iris retractors, including one under the incision; amputating IOL haptics in small bags so it will fit; never placing piggyback IOLs; and performing a lensectomy to help with opening the angle and controlling IOP.
Dr. Zaldivar showed a case where he employed these techniques, saying that all steps within the surgery must be done very slowly. Douglas Koch, MD, said during discussion that another pearl in nanophthalmos is to never let the chamber shallow. “Every time you come out, refill the eye because that’s when choroidal effusions happen.”
‘Astigmatic Keratotomy: Now More Than Ever’
Eric Donnenfeld, MD, said astigmatic keratotomy (AK) is the most underutilized procedure in refractive surgery. “It takes you from good to great. A little incision can go a long way at making these patients happy,” he said, adding that even correcting a small amount of cylinder can be significant.
Dr. Donnenfeld noted the LRI nomogram that he created as well as a diamond knife with a 15-degree angulation, so it’s meant to be used at the slit lamp. Dr. Donnenfeld said he does 5–10 of these a day.
He also spoke about femtosecond laser incisions as an option for astigmatic correction. While he doesn’t think that toric IOLs will be replaced by AK, he is glad to have the procedure for a diopter or less of cylinder that is not corrected by toric IOLs.
“We’ve gone from incisions to laser incisions and now to something even simpler: penetrating LRI,” Dr. Donnenfeld said. With this technique, using the Donnenfeld-Mackool nomogram, he said you can treat between 0.3–1 D of cylinder.
“This allows you to do refractive cataract surgery and you can bill for it as a refractive procedure,” Dr. Donnenfeld said.
‘The Magic of Mentoring’
“Mentoring is one of the most beautiful things that I’ve experienced in our profession, both as mentor and as a mentee,” said Cathleen McCabe, MD.
Overall, Dr. McCabe said mentorship helps accelerate professional development. It expands your network, enhances your confidence, improves your well-being, and gives you exposure to diverse perspectives.
The benefits of mentoring to mentors are that it helps refine teaching skills, provides personal fulfillment, and helps us stay up to date.
To have a successful mentoring relationship, Dr. McCabe said you need to communicate well, have empathy, give constructive feedback, set expectations for the relationship, and share your experiences with them, especially your failures. She also said to set mutual goals, don’t be a crutch for everything, and have periodic evaluations.
“The joy we get in mentoring is one of those things that can’t be quantified,” she said.
Financial disclosures
Donnenfeld: AbbVie, Alcon, Bausch + Lomb, BVI, Johnson & Johnson, Katena, Nordic Pharma, Oculus
McCabe: None
Zaldivar: STAAR Surgical
