This article was reviewed by Barry Emara, MD


	
	Findings from a large retrospective study support the efficacy and safety of dropless

surgery with transzonular injection of a corticosteroid and fluoroquinolone (Tri-Moxi, Imprimis Pharmaceuticals) for preventing postoperative infection and inflammation, according to Barry Emara, MD.
	
	Aiming to characterize outcomes from his first 1,000 patients, Dr. Emara reviewed outcomes in 1,166 eyes that received a 0.2 mL transzonular injection of triamcinolone acetonide and moxifloxacin hydrochloride at conclusion of cataract surgery. The series included all patients who underwent dropless cataract surgery between February 2016, when he first began using the technique, through September 2018.  


	
	Dr. Emara noted that postoperative treatment with a topical corticosteroid was needed by 106 eyes (9.1%), and there were no cases of endophthalmitis. The need for a topical corticosteroid was similar in an updated series that included an additional 221 eyes. In the expanded population, 118 (8.6%) of 1387 eyes required topical corticosteroid treatment, and there were no cases of endophthalmitis.
	
	

Safety key for intracamerally injected mydriatic agents in cataract surgery 


	
	“Efficacy with topical medications used to prevent infection and inflammation after 

surgery is challenged by dependence on patient compliance and the need for the active ingredient to penetrate to the target sites,” said Dr. Emara, adjunct professor of ophthalmology, Schulich School of Medicine and Dentistry, Western University, Windsor, Canada. He also operates his private surgical practice out of the Windsor Surgical Centre.
	
	“Challenges often lead to innovation, and the compounded injectable triamcinolone-moxifloxacin formulation address the need for alternatives to topical medications,” he said.
	
	The study population included 884 eyes of 501 patients who underwent bilateral (383 patients) or unilateral (118 patients) conventional cataract surgery and 282 eyes of 165 patients who had bilateral (117 patients) or unilateral (48 patients) femtosecond laser-assisted cataract surgery (FLACS). A topical steroid was added after surgery when patients presented with symptomatic inflammation.
	
	Dr. Emara noted that additional steroid drops were needed for 72 eyes (8.1%) that had conventional 

 surgery and 34 eyes (11.9%) that had FLACS. In his updated series, additional steroid drops were needed for 82 (7.7%) of 1058 eyes that had conventional cataract surgery and 36 (12.6%) of 329 FLACS cases.
	
	

Pearls to manage cataract surgery on hypotonous eyes 


	
	“From the data it appears that eyes undergoing FLACS are more prone to inflammation than those having conventional 

surgery,” Dr. Emara said. “Based on this information, surgeons might consider pretreating FLACS patients with a topical NSAID or steroid and possibly using a topical NSAID postoperatively to reduce the susceptibility to inflammation.” 
	
	Dr. Emara noted that more than 1 million eyes have undergone dropless cataract surgery in the United States during the past six years, and he cited data reported by other surgeons supporting its efficacy and safety.
	
	Dr. Emara said that placement of the anti-inflammatory and antibiotic medications in the vitreous is preferred over intracameral administration because residence time will be longer in the vitreous and because the vitreous is the site where endophthalmitis establishes itself.
	
	Intravitreal delivery during

surgery can be accomplished by either transzonular injection using a cannula or pars plana delivery with a needle. Dr. Emara said he prefers the transzonular route in which the injection is done after IOL implantation because of its convenience and because it maximizes workflow efficiency.
	
	

Articles

Surgeons explore dropless for cataract surgery 

San Francisco is the city of new beginnings and a leader in education and culture-changing movements that ultimately affect the country and the world. This year’s theme, Inspire!, beautifully reflects the challenge to ophthal-mologists to continue to innovate envelope-pushing ideas and technologies with the goal of providing patients with the best vision possible.
	
	The American Academy of Ophthalmology (AAO) will hold its annual meeting, Oct. 12 to 15, in the City by the Bay.
	
	“The theme for this year’s meeting, Inspire!, serves as an invitation to all members and participants to rediscover what inspires them, network with other industry experts, and continue educating each other on the newest research, technology, clinical developments, etc. moving eye care forward,” said Maria M. Aaron, MD, secretary for the AAO’s annual meeting.
	
	In line with that theme, Inspire! also anticipates the launch of the AAO’s Truhlsen-Marmor Museum of the Eye, set to open in San Francisco in early 2020. The free-to-the-public museum will celebrate the history of ophthalmology, educate the public on the importance of eye health, and inspire the next generation of eye physicians and surgeons.


	The AAO has announced several new additions to its lineup this year. They include:

Complimentary Meetings on Demand products available.


	To take advantage of all the annual meeting has to offer, “Meetings on Demand” is a collection of recorded programming and sessions. This makes it easy for participants to catch up on things they missed or refresh their knowledge after AAO 2019. Starting this year, members who are subscribed for any of the Subspecialty Day meetings will receive complimentary access to the All-Subspecialty Meetings on Demand package. For members who purchase the AAO 2019 Academy Plus course pass, the AAO 2019 Highlights Meetings on Demand package will be included for free.

www.aao.org/annual-meeting/aao-on-demand 

American Society of Ophthalmic Registered Nurses (ASORN) meeting integration
	Starting this year, the ASORN annual meeting, which will run on Friday, Oct. 11 and Saturday Oct. 12, is fully integrated with the AAO’s annual meeting. In an effort to support professional collaboration, ASORN meeting participants will now have access to AAO educational assets, including access to the symposia and spotlight sessions, papers, e-posters, and videos.


	For the first time in AAO history, all posters this year will be in digital form. Members will be able to participate in lively, interactive discussions on the latest e-posters being presented this year. 
	Subspecialty Days
	
	The Subspecialty Day program, beginning one day before the main meeting, covers Friday, Oct. 11 and Saturday, Oct. 12, and is comprised of seven Subspecialty Day meetings during the two-day period.
	
	Ophthalmologists in each subspecialty will have a plethora of exceptional presentations from which to choose during the Subspecialty Day presentations. The programs for all subspecialties can be viewed online through Program Search at 

www.aao.org/annual-meeting/subspecialty-day.


	
	Readers can click the red “Filter” button at the top of the page then choose the “Topics” menu to refine the search results by subspecialty.
	


	Refractive Surgery Subspecialty Day 2019:
	As Far as the Eye Can See
	Retina Subspecialty Day 2019: I2-Inspire Innovation


	Cornea Subspecialty Day 2019: Keeping Disease at Bay
	
	Glaucoma Subspecialty Day 2019: Crossing the Golden Gate to Exceptional Glaucoma Care
	
	Neuro-Ophthalmology Subspecialty Day 2019: Diagnostic Errors and Challenges-Avoid the Traps!
	Oculofacial Plastic Surgery Subspecialty Day 2019: A Decade to Remember 2010–2019
	Pediatric Ophthalmology Subspecialty Day 2019: San Francisco Sound Meets Science Retina Subspecialty Day 2019: I2-Inspire Innovation
	
	


	The opening session and annual business meeting is held from 8:30 a.m. to 10 a.m. on Sunday, Oct. 13. A highline of this session is the Jackson Memorial Lecture that this year will be presented by Emily Chew, MD, director, Division of Epidemiology and Clinical Applications and deputy clinical director, National Eye Institute, National Institutes of Health.
	
	The lecture, titled “Age-related Macular Degeneration: Nutrition, Genes and Deep Learning” will focus on her clinical and research interests in diabetic eye disease and age-related eye diseases.

Marilyn Miller, MD, will receive the Laureate Award during the opening session for her special interest in international ophthalmology and her dedication to preventing blindness and visual impairment in underserved regions in Africa, Asia, and Central and South America.
	
	She is professor of ophthalmology, Illinois Eye and Ear Infirmary, University of Illinois, Chicago.
	
	Another highlight of the opening session is the 2019 Academy Awards that will recognize guests of honor and recipients of the Distinguished Service Award, Special Recognition Award, Outstanding Humanitarian Service Award, Outstanding Advocate Award, International Blindness Prevention Award, Straatsma Award for Excellence in Resident Education, Visionary Society Award.
	
	


	In additional to the keynote address during the opening session, numerous distinguished lectures will be delivered during various symposia throughout the annual meeting

“In addition to artificial intelligence and other leading technologies changing the field of ophthalmology to a look at how millennial physicians are disrupting the industry, this year’s meeting offers myriad timely and fascinating topics,” Dr. Aaron commented.
	
	

10:30 a.m.-12 p.m.
	Marshall M. Parks Lecture, “How Artificial Intelligence Will Affect the Future of ROP Care,”
	Michael F. Chiang, MD.
	
	12:45 p.m.-1:45 p.m.
	Michael F. Marmor Lecture in Ophthalmology and the Arts, “Blind Organists and the King of Instruments,” Bruce Lamott, PhD.
	Arnall Patz Lecture, “The Evolving Pathophysiology and Treatment of Retinopathy of Prematurity,” Mary Elizabeth Hartnett, MD, FACS
	
	2 p.m.-4 p.m.
	Castroviejo Lecture, “Acanthamoeba Keratitis: Getting the Treatment Right,” John K. G. Dart, MD
	3:45 p.m.-5:15 p.m.
	Ruedemann Lecture, “An I for an Eye Removal: Innovations in Enucleation,” Jeremiah Tao, MD
	Whitney G. Sampson Lecture, “Expanding CXL From Keratoconus to Infectious Keratitis,” Farhad Hafezi, MD, PhD


	8:15 a.m.-12:15 p.m.
	Charles D. Kelman Lecture, “Artificial Iris Implantation,” Kevin M. Miller, MD

8:30 a.m.-10 a.m.
	Parker Heath Lecture, “Precision Medicine, Health Economics and Practice Patterns,” Barbara McAneny, MD
	Robert N. Shaffer Lecture, “The Future of Vision Restoration in Glaucoma,” Jeffrey L. Goldberg, MD, PhD
	
	10:15 a.m.-11:45 a.m.
	Wendell L. Hughes Lecture, “Ocular Melanoma: Marching Forward with Imaging, Nanoparticles, and Immunorevolution,”
	Carol L. Shields, MD
	
	12:45 p.m.-1:45 p.m.
	C. Stephen and-Lecture on Uveitis and Immunology, “Ebola, Emerging Infectious Diseases, and the Eye: Patient and Public Health Implications,”
	Steven Yeh, MD

3:15 p.m-4:15 p.m.
	Dr. Allan Jensen & Claire Jensen Lecture in Professionalism and Ethics, “Ethical Aspects of Global Ophthalmic Practice,”
	Anthony J. Aldave, MD

3:45 p.m.-5:15 p.m.
	Barraquer Lecture, “Vector Planning Method: Residual Astigmatism Minimised – LASIK Surprises Avoided,”
	Noel A. Alpins, MD, FACS
	
	
	

8:30 a.m.-10 a.m.
	William F. Hoyt Lecture,
	“CAR-Unexplained Visual Loss,”
	John L. Keltner, MD

10:15 a.m.-11:45 a.m.
	Jones/Smolin Lecture, “New Bugs, New Technologies and New Drugs: Infectious Endophthalmitis in the 21st Century,” Harry W. Flynn Jr., MD
	Zimmerman Lecture, “Wonder and Doubt-The Vasculogenic Mimicry Story,” Robert Folberg, MD


	The conference is planning to offer more than 50 symposia. The AAO highlights a small sampling of these sessions:


	Vascular Disease in Neuro-Ophthalmology
	A Critical Evaluation of Top-Line Data-Cornea Ophthalmic Technology Assessments That Will Change Your Practice
	In This Corner…The Retina Debates, 2019

The Spotlight sessions focus on hot topics in ophthalmology and target the comprehensive ophthalmologist. The following are of special interest:
	
	Spotlight on Cataract: Complicated Phaco Cases-My Top 5 Pearls
	Spotlight on New Technology in Ophthalmology
	Spotlight on Physician Extenders

According to the AAO, other sessions include:
	
	The Evolution and Effect of Genomic Medicine, Blockchain, and Robot-assisted Surgery on the Practice of Ophthalmology (SYM30), Chair: Kevin Thomas Flaherty, MD
	The Impact of AI on Ophthalmology (SYM20)
	Project Human Genome: Genetic Testing for Inherited Eye Diseases (LAB142)
	The Millennial Movement: How Gender Equality, Big Data and Technology Will Be Embraced by the Young Ophthalmologist (SYM52)
	
	

AAO Executives Practice Management Program


	This program gives ophthalmologists the opportunity to learn from the experts, converse with colleagues, and obtain takeaways that you can share and immediately put into clinical. The program includes over 80 instruction courses, seven master classes and two coding sessions, three Saturday specials, a general session, hot topics roundtables, and conversations with the experts.
	
	


	Stop the Bleed Session 1 of this innovative session will run from 1-10 to 11 a.m., session 2 from 11:30 a.m. to 12:30 p.m., and session 3 from 1:30-2:30 p.m.
	
	This session is a new event outside-the-box experience for ophthalmologists to learn to save a life in 30 minutes or less. The AAO points out that ophthalmologists can easily learn to STOP THE BLEED and assist other bystanders while awaiting the arrival of professional emergency responders.
	
	ttendees can participate in a hands-on training for tourniquet application, wound dressing, and packing to save a life in an emergency situation. The course is free and available on a first-come first-served basis.


	While most ophthalmologists focus their energies on their patients, it is also important to remind them to take care of themselves.
	The AAO is working to improve ophthalmologists’ well-being through multiple resources at the annual meeting.
	
	One course that is a must is entitled “Extinguishing Burnout and Reigniting Joy in Medicine,” which is presented by Susan E. Connolly, MD.
	
	Ophthalmologists also are advised to investigate a variety of activities at the Wellness Lounge, West, Booth 7561 and EyePlay Experience, South, Booth 2545. Both of these promote well-being and relaxation and include the use of therapy animals, art therapy, and complimentary seated massages.
	
	


	The Exhibit Hall is located in the North building, Exhibition Level; South building, Exhibition Level; and West building, Level 1.
	Attendees can learn about the latest technologic innovations in the Learning Lounge, the Technology Pavilion, and the Product Theater.
	Visit Ophthalmology Times at Booth 7511.
	
	


	Ophthalmologists should not overlook the instruction courses, original paper presentations, posters, and the Scientific ePoster Theater that too numerous to mention and can be sampled throughout the conference.
	
	

The Academy offers over 350 courses in topics from cataract to vision rehabilitation. This includes over 100 courses in practice management topics such as practice quality and coding & reimbursement.
	
	All instruction courses and Skills Transfer didactic lectures are part of the Academy Plus course pass.
	The Scientific ePoster Theater on the South Exhibition level, offers free 90-minute, small-group, peer-moderated discussions of selected posters in the Poster Theater. Each session will focus on a specific subject.
	
	


	This free venue encourages ophthalmologists to sip free coffee and listen to expert panels debate the issues.
	Participation in the discussions is possible using a laptop or smartphone to send an email or text message with questions to the speakers. The following topics will be discussed uveitis, private equity, cataract, glaucoma, retina, oculoplastics, pediatric ophthalmology and strabismus, and cornea/external disease.
	
	


	The Moscone Center complex consists of three main halls spread out across three blocks and 87 acres in the South of Market neighborhood.
	There are a number of hotels and restaurants within walking distance of the center.

What to expect at this year's AAO meeting 

Focus is on susceptibility to postop CME in eyes with pre-existing vitreoretinal conditions 


	
	A retrospective, population-based, controlled study analyzing data from an unselected patient population undergoing cataract surgery found that neither the need for unplanned postoperative visits for complications nor the incidence of visually disturbing cystoid macular edema (CME) was significantly reduced by adding a topical NSAID to postoperative topical steroid treatment.
	
	The research, however, did highlight increased susceptibility to postoperative CME in eyes with pre-existing vitreoretinal conditions.
	
	

“Results of randomized controlled trials indicate that the occurrence of CME is reduced in eyes treated with an NSAID, either in combination with a steroid or alone,” said Jan GÃ¤rdin, MD, resident, Department of Ophthalmology, LinkÃ¶ping University, LinkÃ¶ping, Sweden.
	
	Dr. GÃ¤rdin noted that it is sometimes difficult to relate study results to what is perceived as clinical reality.
	
	“In our investigator-initiated study including a large number of eyes from an unselected patient population, we were not able to demonstrate a clear benefit for the cohort that received combination therapy,” he added.
	


	BjÃ¶rn Johansson, MD, PhD, co-investigator in the study and associate professor of ophthalmology, LinkÃ¶ping University, said the study has highlighted some interesting treatment options.

“Although randomized controlled studies remain the gold standard for evaluating the efficacy of new treatments, adequately designed and conducted clinical studies such as our retrospective population-based trial are an important complement to clarify how medical and surgical treatments are used in an optimal fashion in unselected clinical populations,” he said. “The findings from such studies may have both medical and economic impact.”
	
	

Large population-based study questions value of routine NSAID use after cataract surgery


	
	The population-based controlled study analyzed data from two groups of consecutive patients operated on in the eye clinics of Vrinnevi Hospital, NorrkÃ¶ping, Sweden and LinkÃ¶ping University Hospital, LinkÃ¶ping, Sweden. The two facilities are in the same county, publicly financed, and under the same regional clinical center, and they use the same electronic patient record system. However, they use different standard protocols for controlling postoperative inflammation, Dr. GÃ¤rdin explained.
	
	


	At Vrinnevi Hospital, patients are treated for three weeks after surgery with a topical steroid and a topical NSAID, each given three times daily. Patients undergoing cataract surgery at the eye clinic of LinkÃ¶ping University Hospital are treated only with a tapering dose of a steroid for three weeks.
	
	Using the electronic medical record system and beginning the search in January 2015, investigators identified a total of 500 consecutive eyes from each hospital. The selected eyes were from patients aged 20 years and older.
	
	Patients were excluded if they had posterior capsular rupture and/or zonular damage preventing in-the-bag IOL placement, deviation from the center’s standard protocol for topical anti-inflammatory treatment, or a pre-existing ocular malformation. Data were extracted on baseline characteristics and unplanned postoperative visits within six months after surgery.
	
	

Controlled trial identifies limited benefits of adjunctive NSAIDs


	
	The two study groups were balanced with respect to gender and right/left eye distribution. Each group had a predominance of females over males and included a majority of right eyes.
	The mean age was about 75 years and similar in the two study groups. Mean logMAR BCDVA was also similar in the two groups preoperatively.
	
	A review of preoperative ocular comorbidities showed the percentage of eyes with pseudoexfoliation was higher in the group that received the steroid alone compared with those treated with combination therapy. The group receiving combination therapy had higher percentages of eyes with an epiretinal membrane (ERM) and with diabetic maculopathy or retinopathy. The number of patients with diabetes and with age-related macular degeneration was similar in the two groups.
	
	Though a higher rate of unplanned postoperative visits was found for the group receiving combination treatment than among eyes treated only with a steroid, the difference was not statistically significant (16.6% versus 12.6%; p = 0.073). CME occurred in eight eyes (1.6%) in the combination treatment group and in six eyes (1.4%) treated with steroid alone.
	
	“The overall incidence of CME in our total cohort was 1.2%, but when patients with diabetes or an ERM were removed, the overall incidence of CME decreased to 0.8%,” Dr. GÃ¤rdin pointed out.
	Clinically significant CME occurred in 2.9% of eyes in patients with diabetes mellitus and in 8.2% of eyes with an ERM.
	
	“The incidence of clinically significant CME among patients in our study who had an ERM was 10-fold higher than in our patients without diabetes and no ERM, indicating patients with an ERM had a drastically increased risk,” Dr. GÃ¤rdin concluded.
	
	

Vol. 44 No. 15

Surgeons explore dropless for cataract surgery

What to expect at this year's AAO meeting

Study targets NSAID use

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