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On Spotlight: The Best Papers of ASCRS 2024

On Day Four at the 2024 Annual Meeting of the American Society of Cataract and Refractive Surgery (ASCRS 2024), moderator Dr. Sumit Garg along with panelists Drs. Brandon D. Ayres, Mina A. Farahani, and Kathryn M. Hatch assembled to discuss the best papers (top 3 in each subspecialty: glaucoma, cornea and cataract; and top 4 in refractive) at the conference this year. 

Glaucoma: The why, the how and the novel

Dr. Manjool M. Shah of NYU Langone Health in New York (USA) tackled the task of choosing the top glaucoma papers from the nearly 80 presented at ASCRS 2024. He highlighted studies that delved into the reasons behind why glaucoma specialists practice, strategies for improvement, and those that offered novel and intriguing insights.  

  1. Carbonell BAC, Kim C, Milhomens Filho JAP, et al. Effect of Topical Antiglaucoma Therapy on Corneal Dendritic Cell Density Using In Vivo Confocal Microscopy

This paper from UC Irvine investigated the effects of antiglaucoma medications on corneal dendritic cell density using in vivo confocal microscopy (IVCM), revealing corneal inflammatory changes induced by long-term medication use.

“Obviously there’s more work to be done in this space,” Dr. Shah said, “But it’s nice to see why MIGS are here to stay. Why surgical and interventional glaucoma is the story now, and I think it’s going to be the standard of care.”

  1. Abdelaal A, Ong J, Schlenker MB, et al. Outcomes of full 360° trabeculotomy versus 180° trabeculotomy without phacoemulsification: An international multicenter study.

This paper, an international multicenter study, compared outcomes of 360- versus 180-degree trabeculotomy, indicating better success with the former despite higher hyphema rates.

  1. Shi Y. In Vitro and In Vivo Vitreous Changes Following Transscleral Cyclophotocoagulation

This paper by Yan Shi (China) explored malignant glaucoma, proposing transscleral cyclophotocoagulation (TSCP) as a potential treatment. It suggested that diode laser energy could liquefy vitreous and damage zonules, relieving angle blockages.

“Sometimes we do these surgical interventions and uncover their efficacy. It actually helps us understand the disease itself,” said Dr. Shah, “This study did a really good job of cracking that code with regards to malignant glaucoma…this dreaded complication that glaucoma surgeons face not too infrequently, but miss all too often quite frankly.”

Refractive: Lenticular extraction, PRK and phakic IOLs 

Dr. Karolinne M. Rocha of the Medical University of South Carolina (USA) presented the standout papers in refractive surgery at ASCRS 2024, reflecting significant progress and challenges in the field. 

On Spotlight: The Best Papers of ASCRS 2024

Dr. Karolinne M. Rocha (left) shares results from a paper on lenticular extraction and visual outcomes.

  1. Khamar P, Shetty R, Roy AS. Understanding Collagen Properties Using Polarization Sensitive OCT (PS-OCT) and Its Role in Deciding the Safe Refractive Procedure.

The first selected paper explored lenticular extraction and impact on visual quality and collagen structure. The study revealed that high-energy lasers resulted in slower recovery of visual acuity and quality. Utilizing advanced technologies such as holotomography and polarization-sensitive OCT(PS-OCT), the researchers assessed collagen structure and tissue density, linking these findings with visual outcomes.

“Differential laser energies of different laser platforms may cause changes in refractive index, and lower energy level may cause less distortion of stromal bed.” summarized Dr. Rocha, “And there was lower phase retardation on PS-OCT post new generation lasers.” 

  1. Mimouni M, Sorkin N, Safir M, et al. Factors Predicting Slow Visual Recovery Following Photorefractive Keratectomy

This paper investigated factors affecting visual acuity recovery following PRK surgery, identifying older age, higher astigmatism correction, and shorter time since contact lens removal as key factors.

  1. Mimouni M, Munzer G, Sela T, et al. Reasons for Retreatment Following Monovision Laser Refractive Surgery: Large Data Analysis

This paper focused on retreatment following monovision laser refractive surgery, highlighting low retreatment rates and identifying the importance of selecting the dominant eye for enhancement.

  1. Micheletti, JM, Hall B. Assessment of Measurement Variability across Automated Biometry Devices

This paper, a phakic IOL study, examined the effectiveness of different devices and the importance of accurate sizing and design. The research compared measurements from various biometry devices, emphasizing the need for adjustment factors to enhance accuracy in ICL sizing and minimize postoperative complications.

Cornea: CXL, AI and MIRV

Dr. Nandini Venkateswaran of Harvard Medical School in Massachusetts (USA) selected papers that covered significant advancements and discussions in cornea surgery, focusing on topics like keratoconus treatment, artificial intelligence (AI) in diagnosis and ocular surface toxicity from systemic medications.

The first selected paper presented outcomes of a modified epithelium-off technique for corneal crosslinking in keratoconus patients who were not contact lens wearers. The technique aimed to address crosslinking complications related to epithelium removal. 

“We all know that crosslinking has become a paradigm shift in how we approach keratoconus, “ Dr. Venkateswaran explained, “But we have not had an FDA-approved epithelium on technique to date, and many of the crosslinking complications that we often see are related to epithelium removal.”

  1. Desilets J, Agarwal K, Hatch KM. Outcomes of Precise Epithelium Removal for Ectatic Corneas Technique (PERFECT) for Corneal Crosslinking (CXL) Among Non-Contact Lens Wearers

By reducing epithelium removal and focusing on non-contact lens wearers, the study achieved effective stabilization of keratoconus progression with minimal complications. Key techniques included swirling the epithelium, loading the cornea with riboflavin, and using pulsed UVA light.

  1. Greenfield JA, Alba D Scherer R, et al. Detection of Ocular Surface Squamous Neoplasia Using Artificial Intelligence with Anterior Segment Optical Coherence Tomography

This paper showcased the use of AI to detect ocular surface squamous neoplasia (OSSN) using high-resolution anterior segment OCT. The AI model demonstrated excellent diagnostic accuracy, sensitivity, and specificity compared to expert clinicians, offering a non-invasive and efficient method for diagnosing OSSN.

  1. Riaz KM, Guillamet AC, Gorp TV, et al. Ocular Safety Results from Phase 3 Mirasol Confirmatory Trial: Mirvetuximab Soravtansine in FRα-Positive Platinum-Resistant Ovarian Cancer

This paper centered on ocular toxicity from systemic medications, particularly focusing on a medication called mirvetuximab soravtansine (MIRV) used in ovarian cancer treatment. The phase three trial of MIRV revealed significant ocular adverse events, emphasizing the importance of ophthalmic safety monitoring during treatment. Despite adverse effects, most patients experienced resolution of symptoms, highlighting the collaboration between ophthalmology and oncology in managing ocular complications.

Cataract: LALs, small aperture IOLs and biomarker predictions

Dr. Mitchell P. Weikert of Baylor College of Medicine in Texas (USA) presented a selection of noteworthy cataract papers, providing valuable insights into emerging trends and innovations in cataract surgery, emphasizing the importance of personalized approaches and ongoing advancements in lens technology to improve patient outcomes.

The first selected paper discussed the efficacy of light-adjustable lenses (LALs) in patients with prior corneal refractive surgery. “I think those of us that do this know that, in prior refractive surgery, it’s hard to get the caps right,” said Dr. Weikert, “So having a lens that’s adjustable is certainly very helpful. But then we have to see how they perform in the eyes.”

  1. Kiser KA, Fortin P, LoBue SA, et al. Visual Outcomes of the Light Adjustable Intraocular Lens in Post-Keratorefractive Surgery Eyes

The study, conducted across four private practices, demonstrated promising outcomes, with a high percentage of eyes achieving target metrics for visual acuity and reduced postoperative cylinders.

On Spotlight: The Best Papers of ASCRS 2024

Dr. Mitchell P. Weikert discusses small aperture IOLs and refractive outcomes in patients with irregular corneas.

  1. Fram NR, Yeu E, Donnenfeld ED, et al. Clinical Outcomes of the Small Aperture IOL for Complex Corneas with Irregular Astigmatism

This paper examined the refractive outcomes of small aperture IOLs, like the Apthera, in patients with irregular corneas. Dr. Weikert emphasized the off-label use of these lenses and presented findings showing favorable refractive outcomes in patients with irregular astigmatism due to corneal issues. The study showcased improvements in both distance and near vision, suggesting the potential of small aperture IOLs in challenging cases.

  1. Shetty N, Shetty R, Khamar P, et al. Novel Biomarker Levels to Identify Risk of Retinal Vascular Progression Post Cataract Surgery

This paper identified biomarkers to predict retinal pathology progression post-cataract surgery, particularly in patients with diabetic retinopathy. “If you’ve got pre-existing severe forms of diabetic retinopathy, we know we’re going to have an increased risk of progression, so we want to be able to predict that more in the patients who have maybe a subclinical presentation or mild forms of diabetic retinopathy,” explained Dr. Weikert.

The study investigated biomarkers like VEGF-A, MMP9, and ICAM1, which were found to be significantly elevated in patients with retinal disease. This research could help in identifying high-risk patients who may benefit from closer monitoring postoperatively.

Editor’s Note: The 2024 Annual Meeting of the American Society of Cataract and Refractive Surgery (ASCRS 2024) was held from 5 to 8 April in Boston, Massachusetts. Reporting for this story took place during the event.

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