As the saying goes, hindsight is 20/20 — and sometimes, people (including ophthalmologists) question their past decisions once new information appears. Thus, seasoned ophthalmologists from the United States shared their wisdom and experience on “things they wished they knew sooner” during the Real World Ophthalmology webinar held on Sept. 18, 2021.
On New and Emerging Therapies
Intraoperative steroid depots are a delivery system used in cataract surgery to control edema. Florida-based ophthalmologist Dr. Cathleen McCabe said that this delivery system improves patient compliance, outcomes and experience while decreasing ocular surface toxicity; it also has a role in complex case management. “One example is the use of Dexycu in cystoid macular edema, diabetic macular edema and manipulation of the iris. They are also useful in the post-COVID environment, which places greater value on compliance-independent, hands-free treatment,” she said.
The next speaker, Dr. Laura Periman from Washington, said that meibomian gland dysfunction (MGD), a common cause of dry eye, is supported by six interrelated mechanisms: bugs (bacteria, Demodex mites); enzymes (lipases, esterases, etc.); inflammation; stasis of meibum; increased melting temperature of the meibum; and obstruction/hyperkeratinization. “This is why, in order to slay all six heads of the MGD beast, we layer therapies (cyclosporine, thermal pulsation, intense pulsed light, hypochlorous acid and omega 3/6) together,” she said. When it comes to surgical treatment, the mindset should be to enable high visual performance under all conditions by protecting the eye, producing healthy tear film, encouraging wound healing, and promoting tear production and homeostasis.
Meanwhile, Dr. Inder Paul Singh from Wisconsin noted that patient compliance in administering glaucoma drops has always been a problem. Hence, he came up with a new therapeutic progression which begins with laser as first-line treatment, followed by minimally invasive glaucoma surgery (MIGS), laser or subconjunctival MIGS, trabeculectomy or tube-shunt surgery, and finally transscleral diode cyclophotocoagulation (TSCPC), with drug delivery and medication at any point of time as needed.
On Newer Refractive Technology
SMILE, which stands for small incision lenticule extraction, is an innovative laser vision surgery that can correct vision for people with higher degrees of myopia. Dr. Audrey Rostov from Washington offered tips for surgeons starting out with this procedure.
She noted that SMILE induces a lesser degree of dry eye, greater tensile strength and less tissue removed in higher levels of myopia than older generations of laser vision correction procedures. “A pro tip is to start with -4.00 diopter and above for your first 20-30 cases — as well as with ‘with the rule’ (WTR) astigmatism, as the lenticule is going to be thicker in the vertical rather than the horizontal degree and therefore is easier to dissect,” she said. “For thicker corneas that are >590 microns, you may need to increase millijoule (mJ) of laser, since it will be a more difficult dissection.”
She also noted that a common issue that surgeons encounter when starting out with SMILE is identifying the anterior and posterior capsules. “When you’re in the posterior, you will feel resistance. Continue posterior dissection until you are beneath the anterior plane. The lower the refractive correction, the thinner the lenticular and the more challenging it may be to find the dissection planes. Hence, if you can’t find the posterior plane, be sure that you haven’t already dissected posteriorly and you can use anterior rescue maneuver,” she advised.
The following speaker, Dr. Nicole Fram from California, talked about maximizing toric outcomes. “Astigmatism impacts patient satisfaction, intraocular lens (IOL) eligibility and quality of vision. Depending on the intraocular lens (IOL) technology, above 0.50 diopter of residual cylinder may leave a patient symptomatic,” she said.
She stressed that preoperative considerations are really important and one should look at the results of the auto refractor (AR), as well as the power of their patients’ current glasses. Online calculators, the Barrett Toric Calculator, and nomograms are helpful.
“When marking toric IOL axis alignment, both old school (e.g., manual marking, slit lamp) and new school (digital marking) can work well if done properly,” she said. Dr. Fram introduced various technologies that can help maximize surgical outcomes, including Veracity Surgical (Carl Zeiss Meditec, Jena, Germany), Verion (Alcon, Geneva, Switzerland), Callisto (Zeiss) and ORA (Alcon).
On Practical Practice Issues
Musculoskeletal disorders in ophthalmologists are very common, with 50-80% developing cervical spine pathologies during their career. Ophthalmologists are also three times more likely to develop back pain compared with family medicine practitioners, noted Dr. Gary Wortz from Kentucky.
“The main culprit is the ‘head forward posture’ that ophthalmologists adopt when they examine patients or perform surgery. The force on the neck exponentially increases the more we bent our neck forward,” he said.
According to Dr. Wortz, ophthalmologists who switched to a heads-up display noticed an immediate improvement; they also could complete more surgeries per day due to increased comfort. He also offered other suggestions, such as modifying the scope height to allow more legroom under the bed; getting an ocular extender which allows the surgeon to sit backward; and taking some time each day to stretch and exercise.
Meanwhile, talking about financial wisdom, Dr. Robert Weinstock from Florida said that one of the most important decisions for an ophthalmologist is regarding practice location. “There are always going to be patients and opportunities. You want to set yourself up where you will be happy. Don’t chase the money, don’t chase the practice. Chase where you want to live for the rest of your life. Almost equally important is the mentorship and sustainability of your practice. The biggest guidance you can get in your career is to have the right people who are going to help you clinically, surgically, philosophically and financially … and who give you advice in all aspects of your life,” he said, adding that fair compensation based on productivity and access to patients are also important factors to consider.
“Also, keep your eyes on surgery center buy-in opportunities. Many successful ophthalmologists have made their greatest wealth in the ownership of surgery centers. Focusing on patient care and experience is the only thing you need to worry about in your entire career. If you focus on giving patients a great experience, you don’t have to worry about money, I promise,” he said.