Feulner is the founder of Advanced Eye Care & Aesthetics in Bel Air, Maryland. She is a paid consultant for EyePoint Pharmaceuticals, Inc.

 This device is easier to insert following and minimize any discomfort after surgery.

 is already a mature and well-refined procedure, I have been delighted to find that new technologies continue to make surgery easier on me and my staff, with better outcomes for patients. 

Here, I will discuss 3 recent cases that illustrate the value of new technology in cataract surgery.

Case 1: Cataract patient with severe untreated glaucoma


The patient was a 73-year-old, non–English-speaking woman referred by a local retina specialist. She had non–insulin-dependent diabetes, as well as high cholesterol and hypertension. 

Her ocular history was significant for diabetic retinopathy and macular cysts in both eyes. She was not on any topical eye drops.

Upon examination, I found that her best-corrected visual acuity (BCVA) was 20/50 OD and 20/40 OS. She had 3+ nuclear sclerosis and 1+ cortical cataracts in both eyes. 

Cataract surgery pearls for cases with poor mydriasis, zonules

The IOP was not high (17 to 18 mm Hg), but she had severe visual field constriction in both eyes, as well as loss of retinal nerve fiber layer and retinal ganglion cells, worse in the left eye than the right. 

The cup to disc ratios were 0.76 oculus dextrus (OD) and 0.72 oculus sinister (OS). 

Pachymetry was slightly thinner than average OU; the angles were narrow but open. I diagnosed the patient with normal-tension 

To address the already-severe glaucoma, we needed to get her pressure significantly lower. 

Given that, along with the patient’s language barrier and financial challenges expressed by her family interpreter, I determined that drops alone might not be successful. 

Fortunately, we have several options to perform minimally invasive glaucoma surgery (MIGS). I particularly like the combination of the microstent (Hydrus Microstent; Ivantis, Inc) and viscocanalostomy with a surgical system (Omni Surgical System; Sight Sciences).

Not only do the 2 together significantly reduce IOP by improving outflow, but performing a 180° canaloplasty gives me the flexibility to come back later and treat the remaining 180°, with or without goniotomy, if I need greater pressure reduction in the future. 

The path to faster visual recovery following glaucoma surgery

Additionally, performing the Omni procedure first opens the channel and makes insertion of the microstent 

The MIGS procedure added only a few minutes to the case, and this patient ended up with an excellent result: 20/20 visual acuity OU and a reduction of her IOP into the 12 to 13 mm Hg range without drops. 

I do not have a nearby glaucoma specialist to refer patients to and would prefer to avoid trabeculectomy for my patients, so being able to use these new technologies to titrate MIGS to disease severity at the time of 


Case 2: Cataract and ocular surface disease


A 68-year-old retired, female patient presented for a cataract evaluation, complaining of decreased vision over the past year (worse in the left eye) and difficulty driving at night due to glare. 

She had previously received a diagnosis of dry eye, MGD and mild age-related macular degeneration. Systemic conditions included arthritis and seasonal allergies.

Upon examination, her BCVA was 20/25 OU, decreasing to 20/50 with glare. She had visually significant regular astigmatism and desired spectacle independence. 

 exam showed just a few drusen and very mild disruption of the retinal pigment epithelium, with normal macular thickness and contour. 

Analyzing macula dystrophy classifications

Her IOP was in the 18 to 20 mm Hg range, with a cup to disc ratio of 0.5 OD and 0.45 OS. There was no history of glaucoma.

and use an intraoperative extended-release formulation of dexamethasone injectable suspension 9% (Dexycu; EyePoint Pharmaceuticals Inc) to deliver a tapering dose of steroid for the first few weeks after surgery. 

In my experience, this intracameral steroid very effectively controls inflammation with little impact on IOP and is an excellent choice for most patients undergoing cataract surgery. 

The ability to reduce or eliminate postoperative drops greatly improves the surgical experience for patients—of particular importance for those receiving premium IOLs and for anyone with 

 because it reduces the amount of toxic preservatives on the eye.

Because this patient had OSD, I wanted to be as kind as possible to the ocular surface and minimize any discomfort after surgery. She was 20/20 uncorrected, and the toric lens was in perfect position after surgery.

On postoperative day 1, the patient had 1-2+ anterior chamber cells, with almost no cells by the 1-week visit and none at the 1-month visit.

VA and visual function go the way of ocular inflammation

Although dexamethasone 9% is a great option for most cataract patients, I recommend initially using it for patients with social, physical, or cognitive limitations that prevent them from administering drops reliably or for patients with severe OSD. 

Once you are comfortable with the injection technique, you can expand your use of dexamethasone 9% more broadly.

Additionally, rather than injecting the spherule behind the iris, as we were initially taught, I prefer to inject it 

 into the capsular bag, where the capsulorhexis overlap of the lens optic and the inferior edge of the lens haptic can hold the spherule in position 

Injecting the dexamethasone injectable suspension 9% spherule into the capsular bag (A) utilizes the capsulorhexis leaflet and the lens itself to hold the spherule in position (B).

With this approach, the medication stays 
in place nicely rather than popping out, especially in a patient with larger pupils.


Case 3: Presbyopia-correcting IOL candidate


A 56-year-old pastor presented for a cataract evaluation with complaints of decreased vision interfering with daily activities and night driving. 

He wore contact lenses to correct for moderate myopia and had previously received a diagnosis of MGD.

Presbyopia-correcting IOL improves vision for patients

Upon exam, BCVA in the left eye was 20/40, worsening to 20/80 with glare. The macula, optic nerve, and IOP were all normal. 

He had 1+ nuclear sclerosis, with a 2+ posterior subcapsular cataract (PSC) OS and 1+ PSC OD. 

He wanted spectacle independence, with a strong need for good intermediate vision for computer work and the ability to see his notes on the lectern in church. I planned femtosecond laser-assisted cataract surgery on the left eye with a PanOptix (Alcon) trifocal lens. 

We discussed that he would wear a multifocal contact lens OD until that eye could be treated and that he would need to stop wearing contact lenses for 2 to 4 weeks prior to biometry.

and potential contact-lens warpage, it is important to look closely at the keratometry and make sure multiple measurements are in agreement before proceeding with a premium IOL. 

Posterior corneal elevation: Is there a role for premium IOLs?

In the past, this would have involved having multiple screens open on my computer and flipping back and forth between screens and printouts.

Since I started using the Veracity Surgical preoperative planning software (Carl Zeiss Meditec), I have been able to quickly see all the patient’s preoperative data from multiple diagnostic devices in our office and compare refractions and keratometry across different devices 

The Veracity Surgical system displays preoperative data from multiple diagnostic devices and shows multiple IOL power calculation formulas. 

(Images courtesy of Lisa K. Feulner, MD, PhD)


I can run multiple IOL power calculation formulas (including toric and postrefractive formulas, when needed) to ensure the correct IOL choice.

Veracity is so much more efficient than the “old” way of doing things. I can tell right away, while the patient is still in the lane, if I will need to bring them back for more biometry after a period of intensive ocular-surface management.

The system also pulls information from our electronic health record system and alerts me to any medical or ocular issues 

 that might affect the outcome, providing an extra measure of safety.

This patient’s Ks were in good agreement at the start. He ended up with a nearly 20/20 uncorrected visual acuity outcome and is looking forward to surgery with the same IOL in the fellow eye.

These just a few of the cutting-edge advancements in the field of cataract surgery.


Feulner is the founder of Advanced Eye Care & Aesthetics in Bel Air, Maryland. She is a paid consultant for EyePoint Pharmaceuticals, Inc.

Articles

Three cases demonstrate value of new tools, technology for surgeons.

Advances in cataract surgery show value in tools, tech for surgeons

With myopia on the rise over the last 50 years, without intervention it is anticipated that half of the world's population may be nearsighted by the year 2050.

This could lead to more people who are dependent upon eyeglasses for good vision, and a large number of those people also could develop vision-threatening eye conditions. It also could result in a flood of patients to ophthalmology practices.

To start a search for solutions, the National Alliance for Eye and Vision Research on Wednesday organized a Congressional briefing held in conjunction with the American Academy of Ophthalmology, the American Optometric Association, Research to Prevent Blindness, and the Association for Research in Vision and Ophthalmology.

Studies estimate that the global impact of uncorrected myopia results in a $244 billion annual productivity loss, while blindness from myopic macular degeneration results in a $6 billion annual productivity loss.

Speaking during the briefing were Katherine Lee, MD, PhD, a pediatric ophthalmologist at St. Luke's Children's Hospital in Boise, Idaho; and Jason Compton, OD, of Compton Eye Associates, in New York, New York.

According to Lee, there are significant eye problems that go along with nearsightedness and most are associated with the retina. These issues include 

, a leading cause of blindness worldwide.

Susan Vitale, PhD, an epidemiologist at the National Eye Institute, pointed out recently that amid the increasing prevalence of high myopia, ophthalmologist can expect to see a corresponding increase in these serious complications.

While screen time has been receiving a lot of press amid the COVID-19 pandemic, Lee noted that myopia trends started before electronic devices dominated everyday life.

“However, use of small electronic devices are a contributing factor, though the science has not caught up with that,” Lee said. “We have not determined that those devices, per se, in and of themselves are significant in causing an increase in nearsightedness.”

Lee noted that there are areas of research seeking alternatives to slow the progression of myopia.

“Nearsightedness occurs in childhood, and the treatments are for children,” she said. “Once you become nearsighted, there isn’t a good way to change it. “

It is known that outdoor sunlight may slow the progression of myopia, and Lee noted that if children spend more time outdoors, it can help slow myopia. New research suggests that adding 30 minutes of daily outdoor activity reduces the progression of myopia in children if the activity is continued.

However, there are few therapeutic options for treatment.

“The dilating drop atropine, at a low dose, can slow the progression of myopia by 50 percent,” Lee explained.

The drops can slow the progression and have fewer side effects compared with a higher concentration preparation, and its use continues to be studied in the US.

Lee also suggests lifestyle changes, including taking breaks form reading, tablets and cell phones.

“Every 20 minutes, users should take a break for 20 seconds and look at something at a distance of at least 20 feet,” she said.

There also are other treatments, according to Lee. Wearing a special contact lens at night can flatten the cornea.

“One of the interesting things about the growth of the eye is that the cells that cause the growth are at the front of the eye,” she explained. “These cells, with traditional correction of nearsightedness, get a blurred image and send a signal to the eye to grow so the eye is in better focus.”

Lee noted that special contact lenses and eyeglasses are designed to give the cells a better image to help control the growth of the eye and slow myopia progression.

A coalition of vision groups held a briefing on Capitol Hill this week to educate legislators on increasing incidence of myopia and the associated cost burden. 

Vision groups sound alarm about myopia during congressional briefing

Bascom Palmer Eye Institute of the University of Miami Miller School of Medicine announced this week that Christopher J. Kaler has received a Research to Prevent Blindness (RPB) Medical Student Eye Research Fellowship, enabling him to take a year off from medical school to devote his time to a research project at Bascom Palmer.

According to the university, Kaler is currently between his 3rd and 4th years of medical school in the combined MD/MPH program at the University of Miami Miller School of Medicine. 

He also has worked part-time in Bascom Palmer’s Ocular Oncology Laboratory since his freshman year of medical school. 

This laboratory takes a broad approach to research, looking at genetics and genomics, cell biology, computational biology, developmental biology and bioinformatics to elucidate new therapies for patients with eye cancer.

Using biochemical, cellular, and genetic methods, Kaler focuses on the dual roles of BAP1 in a rare ocular cancer, class 2 uveal melanoma, and in normal eye development. BAP1 is a gene that provides instructions for making proteins that control cell growth and cell division.

During his RPB fellowship, Kaler will explore functional link(s) between BAP1 loss and aberrant activity of the NuRD (nucleosome remodeling and deacetylase) complex, which normally mediates embryonic lineage commitment and cellular differentiation.

According to the news release, Kaler earned a bachelor’s degree in history, 

, from Boston College and completed the Postbaccalaureate Premedical Program at Columbia University. 

He also worked for two summers as a research student in the National Cancer Institute of NIH.

While at the National Cancer Institute, Kaler studied interactions between the guanine nucleotide exchange factor Vav and protein kinase C isoforms in the Laboratory of Cancer Biology and Genetics headed by Peter M. Blumberg, PhD. 

Kaler also worked for six months as a visiting research scholar at Istituto Superiore di Sanità, Rome, Italy where he performed experiments to identify microRNA biomarkers associated with hepatoblastoma.

J. William Harbour, MD, director of Bascom Palmer’s Ocular Oncology Laboratory and mentor of Kaler, pointed out in the release that it has been known for decades that uveal melanomas become more aggressive by lulling the immune system to sleep so that it does not attack.

“However, the way in which the cancer cells do this has remained a mystery until now,” he said in the release. Christopher’s project is going a long way to solving this mystery and proving new ways to treat uveal melanoma by activating the immune system.”

According to the release, Harbour currently is a professor of ophthalmology, vice-chair for translational research, and the Mark J. Daily Chair in Ophthalmology at Bascom Palmer. 

He will become chair of the Department of Ophthalmology at University of Texas Southwestern later this year. Stefan Kurtenbach, PhD, a Bascom Palmer research assistant professor of ophthalmology, will also serve as a mentor to Kaler.

“The success of the vision research program at Bascom Palmer Eye Institute has been made possible by the generous and sustained support of RPB through the unrestricted grant as well as individual grants,” said Eduardo C. Alfonso, MD, director of the Bascom Palmer Eye Institute and the Stanley J. Glaser Chair in Ophthalmology. “We gratefully acknowledge the RPB support in our prolific scholarly production and value the relationship between RPB and Bascom Palmer Eye Institute as a long-term, mutual collaboration with the shared goals of enhancing the quality of life by improving sight, preventing blindness, advancing ophthalmic knowledge, and innovative vision research.”

Since its founding in 1960, RPB has channeled more than $387 million into eye research. 

As a result, RPB has been identified with nearly every major breakthrough in vision research in that time. 

For information on RPB’s grant programs, listing of RPB institutional and individual grantees, and findings generated by these awards, go to 

Fellowship recipient Christopher J. Kaler will explore functional links between BAP1 loss and aberrant activity of the nucleosome remodeling and deacetylase complex, which normally mediates embryonic lineage commitment and cellular differentiation.

Bascom Palmer Eye Institute receives Research to Prevent Blindness Medical Student Eye Research Fellowship

Watch the previous installments in this series:


What keeps you up at night in ophthalmology?

What keeps you up at night in ophthalmology: Part II

What keeps ophthalmologists up at night: Part III

What keeps ophthalmologists up at night: Part IV

What keeps you up at night in ophthalmology: Part V

What keeps you up at night in ophthalmology: Part VI


What keeps you up at night in ophthalmology: Part VII

Videos

JD Schaub, chief operating officer at RVL Pharmaceuticals, shares what lingers on his mind in the ophthalmic field at the end of the day.

 What keeps you up at night in ophthalmology: Part VIII

Bilateral retinoblastoma (RB) tumors have separate genomic alterations, which can affect both the tumorigenesis and the prognosis for saving the eyes.

Being able to identify the differences between the eyes without the need for enucleated tumor tissue may help direct active management of RB, with usefulness in bilateral cases,

 reported senior author Jesse Berry, MD. 

Berry is based at The Vision Center at Children’s Hospital Los Angeles and USC Roski Eye Institute at Keck School of Medicine of USC in Los Angeles, California.

Great progress has been made in the treatment of this cancer because of discoveries about RB, and mortality rates have decreased; however, patient morbidity remains high. 

AAV gene therapy targets autoimmune uveitis

These patients often have vision loss or may have to lose the eye itself to prevent extraocular disease spread.

“This morbidity is even more impactful in children who have a hereditary disease with both eyes affected,” Berry commented.

Treatment in patients with bilateral RB is further complicated by variable responses in both eyes, despite the same germline mutation in the 

tumor suppressor gene and similar treatments. 

That is likely due to differences in the tumors at the molecular level, Berry explained.

Despite treatment advances, this patient population has not benefited because RB tumors cannot be biopsied directly. 

There is a possibility of intraocular spread, and biopsy tissue is only available when the eyes are enucleated.

Partial visual function restored in patient with retinitis pigmentosa


Berry and colleagues used aqueous humor (AH) liquid biopsy to compare the cell-free tumor DNA from each eye of a patient with bilateral RB tumors. This approach avoided direct tumor biopsies and enucleation.

The authors described the case of a patient with bilateral RBs from whom 5 aqueous samples were obtained: 3 from the right eye and 2 from the left eye. 

An analysis of the tumor in the right eye resulted in its classification as International Intraocular Retinoblastoma Classification (IIRC) group C/stage cT2b.The left eye was group D/stage cT2b.

The patient underwent laser therapy, cryotherapy, and primary intravenous chemotherapy. 

CRISPR technology: A hot topic in gene therapy

Because of persistent vitreous seeding in the right eye following the initial treatment, the patient received 3 intravitreal melphalan injections, which resulted in resolution of the seeds and salvaging of the eye without a recurrence out to 32 months. 

However, seeding persisted in the left eye following chemotherapy, and the patient received 2 intravitreal melphalan injections and 1 intravitreal topotecan injection. 

Despite the treatment, the tumor recurred in the retina and vitreous cavity, resulting in subsequent enucleation 10 months after the diagnosis.

Commenting on the case, the authors pointed out that although the AH samples had the same germline

 mutation, the analysis showed different somatic 

 mutations and separate and distinct chromosomal alterations in the eyes. 

The longitudinal alterations in the tumor fraction corresponded to therapeutic responses in each eye, they reported.

Gene therapy sparks foveal morphologic changes in LCA

“This case demonstrates that bilateral RB tumors develop separate genomic alterations, which may play a role in tumorigenesis and prognosis for eye salvage,” the investigators concluded. “Identifying these inter-eye differences without the need for enucleated tumor tissue may help direct active management of RB, with usefulness in bilateral cases.”

--

 Inter-eye genomic heterogeneity in bilateral retinoblastoma via aqueous humor liquid biopsy. 

.2021;5(1):73. doi:10.1038/s41698-021-00212-0

According to investigators, aqueous humor analysis differentiated the tumors in patients.


Bilateral retinoblastoma tumors: The same but different

A COVID-19 variant, AY.4.2, was recognized earlier in the year in the UK, but is now gaining attention because of its surge there, according to the UK Health Security Agency.

AY.4.2, which some are calling "Delta plus," contains mutations that might give the virus survival advantages. In addition to its rise in the UK, the Delta subvariant has been found around the world in 27 countries.

“UK reported its biggest one-day Covid case increase in 3 months just as the new Delta variant AY.4 with the S:Y145H mutation in the spike reaches 8% of UK sequenced cases,” Scott Gottlieb, MD, former FDA commissioner, said in an Oct. 17 tweet. “We need urgent research to figure out if this Delta plus is more transmissible, or has partial immune evasion.”

The Delta variant still predominates in the US and UK, but the U.S. Centers for Disease Control and Prevention (CDC) mentions the AY variants as a concern, and suggested that it may be more contagious and more severe than the original COVID-19 strain.

As of now, not a great deal is known about this variant and its danger to the public. However, it is clear that it is slowly gaining a grip in the UK.

Gottlieb urged that investigators quickly characterize this variant and others as they pop up.

According to Newsweek, the variant is not currently listed as a distinct variant of concern or a variant of interest by the U.K., World Health Organization, or the CDC.

Francois Balloux, director at the University College London Genetics Institute, said on 

 that data about AY.4.2 suggested it could be 10 percent more transmissible than the most common 

"As such, it feels worthwhile keeping an eye on it," he said.

The Delta variant still predominates in the US and UK, but the CDC mentions the AY variants as a concern, and suggested that it may be more contagious and more severe than the original COVID-19 strain. 

COVID-19 evolution: AY.4.2 Delta variant on the rise in UK

Schuman is the Elaine Langone Professor & Vice Chair for Ophthalmology Research, NYU Grossman School of Medicine, NYU Langone Health, New York University, New York, New York, and a member of the editorial board of 

) scan?

My guess is it is not often enough.

We must be discerning when choosing to accept results of an OCT scan, with quality determining the accuracy of the segmentation of the retinal layers.

That segmentation provides the numbers we use to determine whether disease is present and progressing.

We must know whether the OCT image quality is adequate, and whether the OCT segmentation is correctly defining the retinal layer borders of interest.

The problem is that even if the segmentation is wrong, the OCT will report a value. This is what results in so-called “red disease.”

The values will be reported in the data tables and labeled with green, yellow, or red and will be shown on the volumetric scan data, such as the “heat maps” of retinal, GCIPL, GCC, or RNFL thickness.

 using these displays — or using the comparisons to the normative database, such as the deviation map — can be misleading if the segmentation has not properly defined the relevant tissue borders.

We must consider factors that will result in poor image quality and poor retinal layer segmentation and decide whether what we are seeing and measuring is real.


Conditions affecting signal quality include the condition of the ocular media, such as cornea lubrication, cataracts, and vitreous opacities. The focus will be affected by refractive error. 

The farther from the anteriormost scan point the focus is, the poorer the scan quality and resolution with spectral domain OCT will be.

Scan alignment and the polarization setting impact image quality. There can be vignetting of the scan due to signal deterioration at the pupillary edge.

Scan quality will be enhanced in SD-OCT by keeping the image close to the zero-delay, because signal quality is highest at the top third of the scanning window.

The tissue in the scan should appear as flat as possible.

Other factors can affect the scan quality, from blood vessel shadows to eye movement.

The only quantitative parameter we have for assessing image quality is an amalgam of signal-to-noise ratio and other proprietary factors specific to a given device manufacturer.

Organ donation: "Dead donor rule" sets guidelines or harvesting organs

The nominal values for devices in the United States are:


There is no measure of segmentation quality with any of the OCT devices, short of subjective evaluation by the user to see whether the borders outlined by the algorithm seem to match the visible relevant tissue layer borders.

 interpretation. The retina is thinner than in emmetropic or hyperopic eyes and can be highlighted as abnormal because of this thinness.

OCT can be a boon in the assessment of glaucoma and must be interpreted to ensure results are accurate and not driven by artifact.

The time taken to assess OCT image and segmentation quality pays off for physician and patient and enhances the quality of care that we are able to provide.

 the Elaine Langone Professor & Vice Chair for Ophthalmology Research Department of Ophthalmology, NY

U Grossman School of Medicine, NYU Langone Health, New York University, New York, New York, and a member of the editorial board of 

There are times when physicians should be critical of scans.


Should we always trust the OCT?

Eye candy exam

Researchers led by Liza Cohen, MD, from the Division of Orbital and Ophthalmic Plastic Surgery, Stein Eye Institute, Doheny Eye Institute, Los Angeles, reported that development of involutional ptosis may be a multifactorial process.

The investigators conducted a case-control, observational cohort study

 in which they assessed systemic medical conditions and types of ocular surgery and the risk prevalence of ptosis in adult patients.

Data were drawn from a 10-year period from the electronic medical records of 5 academic medical centers. 

Patients were included in the study based on their International Classification of Disease codes 9 and 10 for involutional ptosis; systemic comorbidities were also determined based on these codes. 

The patients were matched by age and gender with controls from the general population.


A total of 8,297 adult patients with involutional blepharoptosis and 13,128 matched controls comprised the study cohort (average age, 65 years). 

The investigators reported that the 3 significant risk factors for developing ptosis were ocular surgery, hyperthyroidism, and type II diabetes (odds ratios, 4.2, 2.5, and 1.45, respectively; p< 0.05).

“Strabismus, corneal, and glaucoma surgeries were more highly associated with developing ptosis (p < 0.05). 

Strabismus surgery had the greatest odds ratio of 3.37, followed by corneal surgery with an odds ratio of 2.31 and glaucoma surgery with an odds ratio of 1.56,” they said.

“Involutional ptosis is likely a multifactorial process. This study demonstrated that risk factors for the development of ptosis include ocular surgery, specifically strabismus, corneal, and glaucoma surgery, and hyperthyroidism and type II diabetes,” the team concluded.


1. Cohen LM, Campbell BC, Esfandiari M, et al. Ophthalmic surgeries and systemic medical conditions associated with the development of involutional ptosis. 

2021;37:133-7; doi: 10.1097/IOP.0000000000001707

The development of involutional ptosis may be a multifactorial process, researchers have found. 

Eye candy exam

Causes of involutional ptosis

FDA approves Genentech’s Susvimo