Surgeons should use all tools and techniques available to better manage small pupils. (Image courtesy of Kendall E. Donaldson, MD, MS)

	When managing a small pupil during cataract procedures, surgeons should take their time and use all the tools in their armamentarium for successful outcomes, said Kendall E. Donaldson, MD, MS.

	Dr. Donaldson shared the example of a normal-sized versus small pupil and what would happen if the size of each one decreased by 2.5 mm. For a 6-mm pupil, that change decreases the operative field by 66% versus 50% for an 8.3-mm pupil.

	“Not being able to see can complicate cataract surgery,” said Dr. Donaldson, associate professor of ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami.

	Small pupils often are not the only problem a surgeon will manage in these complicated cases.

	“There’s often intraoperative floppy iris syndrome, pseudoexfoliation, diabetes, uveitis, longer surgery, prior surgery or trauma, and use of the femtosecond laser,” Dr. Donaldson said.

	Always examine the other eye as well for potential small pupil issues, she added.

	Dr. Donaldson addressed the research that reported that femtosecond laser (FLACS) use could lead to a smaller pupil.

	“Fortunately, 96% of the time, that’s reversible with intracameral, preservative-free phenylephrine followed by a dispersive viscoelastic. However, about 4% of the time, it’s not really reversible,” she cautioned.

	One pearl she suggested is to avoid femtosecond laser use in higher-risk patients with pre-existing small pupils.

	Dr. Donaldson shared the example of cataract surgery in a 4.7-mm pupil with a history of floppy iris syndrome. Uneventful lens fragmentation and capsulotomy were performed, but three minutes later, the pupil went down to 2.5 mm. It did not improve with the use of lidocaine or a dispersive viscoelastic material.

	“I did have to put in a Malyugin ring in this case. I would recommend after you make a primary wound, put viscoelastic beneath the iris and lift up the iris to safely place the Malyugin ring without grabbing the edge of the capsule in these FLACS cases,” she said.

	Surgeons have a number of additional tools and techniques they can use, including:

	> Pretreating with nonsteroidal anti-inflammatory drugs

	> Use of ketolorac/phenylephrine injection 1%/0.3% (Omidria, Omeros Corp.)

	> Phaco chop, as discussed by David Chang, MD, San Francisco. “He taught us that chopping can put less energy into the eye with minimal movement in anterior chamber. It can be done with small pupils very safely to minimize lenticular movement, especially in pseudoexfoliation syndrome where we don’t want to have extra stress on the zonules. Phaco chop is an excellent technique in these cases,” Dr. Donaldson said.

	This article was adapted from Dr. Donaldson’s presentation at the 2017 meeting of the American Academy of Ophthalmology. Dr. Donaldson is a consultant for Alcon Laboratories, Allergan, Johnson & Johnson Vision, and other ophthalmic companies.

Articles

Small pupils usually travel in clusters with other surgical challenges. Kendall E. Donaldson, MD, MS, explains how surgeons may better manage small pupils during phacoemulsification by employing all tools and techniques available to them.

Strategies for small pupil phaco

The day has finally arrived. You take a moment to reflect on the path leading up to the next stage in life. Medical school, residency, starting a practice, saving toward retirement, putting the children through college, paying for a wedding or two. You have been hardworking, diligent, and disciplined in your planning and preparation.

You are ready to transition into a deserved and anticipated retirement, which includes traveling, working on the golf game, helping the grandchildren with college, and spending time with loved ones.

The date is October 2000, and the beginning of the tech bubble. During the dot.com bubble, the NASDAQ Composite 

 saw the S&P 500 decline 57.8% between October 2007 and March 2009.

You have spent 40-plus years in a profession that has helped countless patients and has provided you with the financial means to live a comfortable retirement. Now, due to forces out of your control, your retirement dreams and aspirations are in question.

The timing of your retirement has the potential to dictate one’s retirement success as measured by the ability to sustain a desired quality of life without running out of money.

A recurring question over the years has been: “Do I have enough assets to retire or will I run out of money some day?”

That is a simple question, but one that is complicated by the unknown – will you retire in the beginning of a bull market or a bear market? At what point in the financial cycle will you be forced to start drawing on your portfolio?

The sequence of returns, as it is referred to, can produce starkly different answers to these questions.

The good news is there are strategies that can mitigate those detrimental consequences of retiring at the wrong time. Here are six ways to protect yourself and your portfolio:

The most important step is to know how much money you will need in retirement. We recommend that before retiring, take the time to determine a 

 budget, and do not underestimate your expenses.

These expenses should be broken down into recurring essential expenses (e.g., food, utilities, mortgage, property taxes, etc.) and discretionary expenses (vacations, dining out, gifts, etc.). If the market declines for a year or two, you can use a predetermined formula to adjust discretionary expenses based on a percentage withdrawal of the portfolio balances.

Knowing how much you should have in equity exposure is an important determination. There is no reason to have a higher percentage in the stock market than is needed for future growth to meet goals and objectives. If your retirement looks sound with an allocation of 50% in the stock market, then there is no reason to assume more risk,

The benefits of the potential gains will not affect your lifestyle, but the consequence of the potential losses could be devastating. These are critical calculations to review in retirement preparation.

Step 3: Hold asset classes that do not all correlate with one another

Design a portfolio that is exposed to various asset classes, different management styles, and different sectors. One should add investments that do not have a high degree of correlation with the stock market and alternative investments. This methodology can assist in reducing potential volatility while smoothing out future rates of return.

Always keep a cash reserve available that represents a minimum of six months of living expenses. These funds will be available for any unexpected expenses.

Consider some of the hedging techniques that are available. You may be able to protect a portion of your equity portfolio from a certain percentage to the downside.

Sometimes, this means giving up a little on the upside, but preservation of principal is important in a declining market, while still giving you upside potential. Some of these strategies are available through annuities.

Over the years, the annuity market has received its share of bad press regarding high fees and lack of flexibility. Some new annuity products have improved over the years and they can provide a useful role in a portfolio.

Part of a defensive strategy can be matching a guaranteed income stream from an annuity contract to a certain percentage of essential recurring expenses. This income is reliable, even in a down market, and can be guaranteed for life.

A reduction in principal will not change this income and, even if the principal were to be depleted, the income will continue.

Compare your actual spending to planned spending annually and make sure that you are not exceeding target withdrawals.

Forecasting the economic and financial climate when you retire is akin to a meteorologist forecasting the weather 2, 10, or 20 years into the future. It is little more than an outright guess.

By implementing the strategies above however, you can be better prepared to successfully navigate any financial storm that may come your way in retirement.

John J., John S., and Traudy F. Grande, CFPs, are the editors of the Money Matters column. They are owners and principals of Grande Financial Services Inc., Oakhurst, NJ, (www.grandefs.com) and registered principals of Wells Fargo & Co., member of SIPC. The Grandes advise doctors across the country on a diverse range of investment and financial matters. Readers may submit their financial questions to them at john.s.grande@wfafinet.com or call 800-722-1258.


	Wells Fargo Advisors and its Financial Advisors provide non-fiduciary services only. They do not provide investment advice (as defined under the Employee Retirement Income Security Act of 1974 as amended [“ERISA”]), have any discretionary authority with respect to the plan, make any investment or other decisions on behalf of the plan, or otherwise take any action that would make them fiduciaries to the plan under ERISA.

The views expressed by the authors are their own and do not necessarily reflect the opinion of Ophthalmology Times, Wells Fargo Advisors Financial Network, or its affiliates.

Wells Fargo Advisors does not provide legal or tax advice. Be sure to consult with your tax and legal advisors before taking any action that could have tax consequences.

Variable annuities are long-term investments suitable for retirement funding and are subject to market fluctuations and investment risk.

A Guaranteed Minimum Income Benefit (GMIB) feature is an optional rider on a variable annuity that is available for an additional annual charge against the income base. It generally may only be selected at the time of contract purchase and cannot be changed later. It can usually be exercised only after a waiting period. A GMIB feature is not a cash or account value. Please be advised that depending on the performance of the investment option selected, the contract value at the time of annuitization could be such that the investor would incur a higher expense with the GMIB option without receiving any additional benefit.

Unlike variable annuities, equity indexed annuities (EIAs) are typically structured so that they are not securities registered with the SEC. Nor are the sales in EIAs regulated by the SEC or FINRA Regulation Inc.

Fixed annuities may have a higher initial interest rate which is guaranteed for a limited time period only. At the end of the guarantee period, the contract at a lower rate.

Investments in securities and insurance products are: NOT FDIC-INSURED/NOT BANK-GUARANTEED/MAY LOSE VALUE. Investment products and services are offered through Wells Fargo Advisors Financial Network, LLC (WFAFN), Member SIPC. Grande Financial Services Inc. is a separate entity from WFAFN.

6 steps to weather a possible financial storm in retirement

	It’s been six years since the Association for Research in Vision and Ophthalmology (ARVO) decided to unmoor its annual meeting from Fort Lauderdale, FL, and start rotating around the country. This year’s destination is sure to appeal to many people: Honolulu.

	The meeting, set for Sunday, April 29 through Thursday, May 3, will include 11,000 international basic and clinical researchers sharing the latest news in vision research. Attendees can also enjoy beautiful beaches, warm weather, and a vibrant city filled with activities while visiting, of course!  

	Here are some of the highlights planned for this year’s meeting.

Jennifer Doudna, PhD, will deliver the keynote speech, “CRISPR-Cas Gene Editing: Biology, Technology and Ethics.”

	As an internationally renowned professor of chemistry and molecular and cell biology at UC Berkeley, Dr. Doudna and her colleagues described a simple way of editing the DNA of any organism using an RNA-guided protein found in bacteria in 2012. This technology, called CRISPR-Cas9, has opened the floodgates of possibility for human and non-human applications of gene editing, including assisting researchers in the fight against HIV, sickle cell disease, and muscular dystrophy.

	According to ARVO, gene editing with CRISPR technology is transforming biology. Dr. Doudna will discuss how bacterial CRISPR adaptive immune systems inspire creation of powerful genome engineering tools, enabling advances in both fundamental biology and applications in medicine. She also will discuss the ethical challenges of these applications.

.
	Shoukhrat Mitalipov, PhD, will speak on the topic “Principles of gene repair in human embryos.”

	Dr. Mitalipov is director of the Center for Embryonic Cell and Gene Therapy of Oregon Health & Science University (OHSU) and a professor in the Division of Reproductive and Developmental Sciences at Oregon National Primate Research Center, OHSU. Dr. Mitalipov’s research interest is to understand the mechanisms of cytoplasmic control of nuclear genome identity and reprogramming of somatic cells to the totipotent and pluripotent states.

	Another objective is to develop novel germline gene therapy approaches for the treatment of inherited human diseases. He is investigating novel germ line gene therapy approaches that would allow for the repair of gene defects in mutant gametes or early pre-implantation embryos. This lecture will discuss applications of gene editing and gene replacement strategies in preclinical and clinical studies demonstrating feasibility, efficacy, and long-term safety of germ line gene therapy.

Proteostasis networks: Challenges and therapeutic opportunities for ocular diseases: 

Learn the pathways, translational opportunities, and challenges for the management of eye diseases offered by targeting Proteostasis networks.

Ocular and Systemic Circadian Rhythms: Implications in Vision Research Organizers:

 Consider how circadian rhythms and diurnal patterns affect the eye and other systemic processes.

In Galileo’s Footsteps: visualizing immunity: 

Explore the novel methods that have emerged in recent years that allow clinicians and scientists to directly image immune-mediated events.

Neuronal Health in AMD and Glaucoma: Lifestyle-based Therapies to Live Long and Prosper: 

Learn about the involvement of oxidative stress and mitochondria in exercise, epidemiology, and epigenetics, and the biochemistry of diet and nutritional interventions. 

Implementation science in ophthalmology, 

20/20 visual acuity is not enough – again, 

Circadian clocks in retinal health and diseases, 

Targeting mitochondrial dysfunction in retinal and optic nerve disease, 

Corneal regeneration in health and disease

rom optics to electronics: New technologies for improving vision in health and disease,

Molecular and cellular insights into lens and cornea regeneration

The nuts and bolts of novel drug development

Metabolic regulation of ocular immune responses,

Treatment on the horizon for Fuchs endothelial corneal dystrophy,

Retinal lipid and glucose metabolism in health and disease

	Learn while having bite to eat first thing in the morning! Breakfast with an Expert sessions will be held Wednesday from 6:45 to 8:15 a.m. Here’s the 

How to start your international career and contacts

Private/non-profit funding opportunities for early-career scientists

Philip I. Murray, PhD, FRCP, FRCS, FRCOphth: 

Effective communication: tips for presenting and publishing

Career options after graduate and professional school: academia, industry or hybrid

Transitioning from student to post-doc to faculty

Your dream experiment just worked! What’s next? How to sell it in papers and grants

Can I still have it all? How to successfully combine clinical ophthalmology and research and still be fully funded in 2018

Thinking outside the box: Alternative careers for the clinician scientist or researcher

How do I fit in and thrive? For biostatisticians and epidemiologists in vision research

: Developing a Career as a Clinician Scientist

Setting up spinoffs and conducting commercial research from an academic lab

Robert AH Scott MBBS, FRCS(Ed), FRCOphth, DM: 

Connecting clinical practice with research

Applying to ophthalmology residency programs

	For attendees whose interests are not easily defined by just one section, consider these cross-sectional platform sessions. Check online for times.

Get updates on visible OCT’s limitations and future directions.

Making good on the promise of genetics for eye diseases: The successes and challenges along the translational pathway: 

Explore how genetic knowledge is changing management of hereditary eye diseases and how we can overcome the challenges of genomic medicine.

Clinical researchers, experts share the latest news in vision research, focusing on the power of genetic therapy

ARVO 2018 says ‘Aloha!’ to Hawaii for annual event

Findings of a study determining the prediction error in the magnitude of residual astigmatism after cataract surgery with a toric intraocular lens (IOL) suggest that use of intraoperative wavefront aberrometry for toric power selection could enhance the refractive outcome in a large subset of eyes.

The study included 50 eyes of 38 patients implanted with a toric IOL (SN6ATx; AcrySof IQ Toric IOL, Alcon Laboratories). In all cases, the toric power of the implanted IOL was determined using an intraoperative wavefront aberrometer (ORA System, Alcon Laboratories). The residual astigmatism predicted by the device was noted.

In addition, IOL power calculation was performed for all eyes with the toric IOL manufacturer’s online calculator that uses the Barrett Toric Algorithm, a nomogram that theoretically accounts for posterior corneal astigmatism. Using the subjective refraction measured at 3 months postoperatively, the predicted residual astigmatism for the implanted toric IOL was back-simulated using the toric IOL calculator.

For the main outcome analysis, the difference vector was calculated for each prediction method by subtracting the predicted residual astigmatism vector from the observed postoperative astigmatism vector.

The median of the magnitude of the astigmatism difference vector (MedAE) was compared for the 2 methods, and the results showed that the overall prediction error in residual astigmatism was the same for the intraoperative wavefront aberrometer and the toric IOL calculator.

However, in a subgroup of 26 eyes in which there was a mismatch between the implanted toric power determined by intraoperative wavefront aberrometry and that suggested by the toric IOL calculator, the prediction error for the same implanted toric power was significantly lower using the intraoperative wavefront aberrometer compared with the toric IOL calculator.

“We have found preliminary evidence that intraoperative wavefront aberrometry can increase the accuracy of residual astigmatism prediction in a significant subset of eyes when compared to a recently introduced toric IOL calculator that already accounts for posterior corneal astigmatism,” said Miguel Raimundo, MD, Department of Ophthalmology, Centrao Hospitalar e UniversitÃ¡rio de Coimbra, Coimbra, Portugal.

“Nonetheless, further studies are warranted, for instance for replication of the findings, using a larger sample size, or to address some of our study’s limitations,” Dr. Raimundo added. “One of these might be testing other sources of anterior keratometry data because this might compromise the accuracy of the preoperative calculation.”

Dr. Raimundo and colleagues were motivated to conduct this study because evidence on the use of intraoperative wavefront aberrometry to guide toric IOL power selection is relatively scarce.

“To the best of our knowledge, only three studies exist,” Dr. Raimundo pointed out. “Two studies showed it improved toric outcomes, but the third showed that intraoperative computed-assisted registration with a preoperative toric calculator yielded less remaining refractive cylinder than intraoperative wavefront aberrometry. So, the debate is still open on the usefulness of the technique.”

The 50 eyes included in the study represented a consecutive series that underwent uncomplicated surgery. Eyes were excluded if they had preoperative best-corrected visual acuity (BCVA) <20/40, cornea ectasia, previous refractive surgery, any conditions that would compromise the accuracy of the postoperative refraction, or any additional astigmatism corrective procedure.

Preoperative biometry measurements were obtained with the same device (IOLMaster 500, Carl Zeiss Meditec) in all cases. The intraoperative wavefront aberrometry measurements were taken after the anterior chamber was inflated to a normotensive level with cohesive viscoelastic, as verified by a Barraquer tonometer.

Among the 26 eyes in which the cylindrical power selected by intraoperative wavefront aberrometry differed from that recommended by the toric IOL calculator, intraoperative wavefront aberrometry recommended a lower power than the toric IOL calculator in 19 eyes.

To assess if the eyes in which a mismatch occurred differed in any way from those where the 2 methods suggested the same power, the biometric data of the 2 subgroups was compared. The analyses showed no significant differences in mean preoperative keratometry, corneal astigmatism, axial length, or anterior chamber depth.

“In the subgroup of eyes where the IOL toric calculator would have predicted a different IOL cylindrical power, we found the intraoperative wavefront aberrometer was able to get a lower median absolute error for residual astigmatism compared to the toric IOL calculator,” Dr. Raimundo said.

This article is based on a presentation given by Dr. Raimundo at 2017 American Academy of Ophthalmology meeting. Dr. Raimundo has no relevant financial interests to disclose.

Intraop wavefront aberrometry may enhance results in toric IOL surgery

Deciphering cellular and tissue responses in glaucoma are key to preventing and curing the disease. Some recent insights into the behavior of cells subjected to mechanical insult due to increased intraocular pressure (IOP) and changes in the stiffness of the sclera are helping to unravel the secrets of glaucoma.

One important observation is that the cells in the optic nerve head (ONH) are sensitive to mechanical changes.

“In general, cells are mechanosensitive and will, for example, migrate to a preferred substrate stiffness,” said C. Ross Ethier, PhD, the Lawrence L. Gellerstedt, Jr., Chair in Bioengineering, Georgia Research Alliance Eminent Scholar in Biomechanics and Mechanobiology, and professor of biomedical engineering, Georgia Institute of Technology/Emory University, Atlanta.

Dr. Ethier provided an example of this preferential activity. When a cell is released from the soft side of a gel, the cell migrates to the stiff side of the gel. In the opposite scenario, when the cell is released on the stiff side of the gel, the cell does not move to the soft side.

“This behavior tells you that cells have the ability to sense the mechanical properties of their substrate and respond to them,” Dr. Ethier emphasized. “We now know that substrate stiffness influences cellular growth, motility, apoptosis, and even differentiation of stem cells.”

All of these activities have shown investigators that nearly all cell types contain sophisticated machinery for sensing and responding to mechanical stimuli, he explained.

One such cellular system is the YAP-TAZ pathway, which, in addition to responding to substrate stiffness, also responds to the softness and stiffness of three-dimensional (3-D) matrices and stretching resulting from pressure, which is relevant to the ONH.

This structure is a major player in glaucoma, and the importance of determining why it is vulnerable to pressure, among other forces, cannot be overemphasized. Computational modeling of the ONH predicts high mechanical strains in the ONH tissues, indicating that the ONH is a weak spot in the otherwise tough corneoscleral shell, Dr. Ethier demonstrated.

Image 1. A slice through the lamina cribrosa as seen by OCT. (Image courtesy of C. Ross Ethier, PhD)

Experimentally, micro-computed tomography 3-D imaging of the ONH region of an enucleated porcine eye showed the strains that occurred when the eye was subjected to different IOP levels. For example, the anterior and posterior lamina cribrosa within the ONH undergo significant stretching and compression as IOP increases, corresponding to deformations thought to exceed safe ranges that the cells can tolerate.

Cerebrospinal fluid pressure also can affect strains in the ONH. “We know that when looking at the average or peak strains in the lamina cribrosa or in the retrolaminar neural tissue just posterior to the lamina, the strains are well outside of the safe ranges, especially in the retrolaminar neural tissue,” Dr. Ethier said.

Another potentially important factor is optic nerve tension. Investigators who recently used a numerical model to look at the effect of tension in the optic nerve sheath on the ONH found, surprisingly, that traction forces in the optic nerve sheath were great and created stress in the peripapillary tissue nasally and temporally (Wang et al. 

57:2452-2462. doi: 10.1167/iovs.15-18986).

Image 2. A 2-D reconstruction of the lamina from a 3D micro-CT scan. (Image courtesy of C. Ross Ethier, PhD)

When those investigators then looked at the effects in a small clinical cohort using optical coherence tomography, they also surprisingly found large strains in the lamina cribosa. With ocular movements, specifically adduction, strains in the lamina cribosa were found to be “quite significant,” according to Dr. Ethier.

The observed strains were comparable to the strains seen due to IOP increases (Wang et al. 

 2016;57: 5825-5833. doi:10.1167/iovs.16-20560

The same investigators also identified that the optic nerve sheath is tighter with greater tension in patients with glaucoma. Dr. Ethier noted that the clinical relevance of this is not yet clear, but he believes it is necessary to consider more than just IOP when thinking about glaucoma.

When this information is considered clinically, Dr. Ethier said the sclera is an important factor. “The sclera matters a lot: mechanical strains in the ONH are thought to be much higher in eyes with a soft sclera, thus leading to the possibility of altering the course of glaucoma by intervening to stiffen the sclera,” he said.

In an experimental rat study, the sclera was stiffened, ocular hypertension induced, and the optic nerves followed. Importantly, the preliminary results showed the stiffening protected against axonal loss. “This is extremely interesting and provocative,” he commented.

However, in another study performed in mice, the opposite was found. “The scientific questions remain very much open and there is still a lot to be discovered,” Dr. Ethier said.

Lastly, Dr. Ethier commented on an in vivo study that estimated the biomechanics of the ONH by segmenting the tissues and computing the deformations of the ONH in control subjects and in patients who had undergone filtering surgery. The investigators found large reductions in strains in certain patients.

“The ability to interrogate the ONH and the mechanical strains in this tissue is slowly being translated to a clinical environment,”  Dr. Ethier. “This will help us understand what is happening biomechanically in glaucoma in the ONH.”

This article was adapted from a presentation Dr. Ethier delivered at the Glaucoma Subspecialty Day, held prior to the 2017 American Academy of Ophthalmology meeting. Dr. Ethier has no financial interest in any aspect of this report

Investigations of the biomechanical changes in the optic nerve head may eventually lead to improvements in therapies for patients with glaucoma.

Vol. 43 No. 06

Strategies for small pupil phaco

6 steps to weather a possible financial storm in retirement

ARVO 2018 says ‘Aloha!’ to Hawaii for annual event

Intraop wavefront aberrometry may enhance results in toric IOL surgery

Investigating strains on ONH tissue key to unraveling mystery of glaucoma