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There are four areas in which I plan to hone my skills in 2019:

• Corneal regeneration. This is an important topic and a new type of surgery that could provide an alternative to corneal transplantation through ocular surface regeneration therapy, stromal regeneration therapy, and endothelial cell transplantation.
• Accommodating IOLs. We are studying the Lumina (AkkoLens), which is now in phase 3 clinical investigation. We must further understand the behavior of this lens in the long term and the maintenance of its previously published accommodative ability.
• Corneal lamellar surgery. Hyperopic small-incision lenticule extraction is the next step. I look forward to the development of better algorithms to avoid undercorrection in high myopia.
• Microinicision cataract surgery. We have the capability to operate through incisions of 1 mm with 0.7-mm probes, but we are unable to insert a lens through this opening. Further IOL designs will soon help us to overcome this challenge.

  My biggest questions in ophthalmology from 2018 are:

  • How can we prevent aging of the crystalline lens and especially the retina?
  • How can we use gene therapy to treat genetic disorders in the eye?
  • How can we further develop international cooperation to decrease cataract-related blindness in the developing world?”

I believe that, in the next decade, our specialty will place a necessary emphasis on glaucoma management for anterior segment surgeons. I am now retired from patient care, but if I were still practicing, I would plan to become facile with the iStent inject (Glaukos) specifically. I believe no patient with glaucoma should have cataract surgery without consideration of a combined microinvasive glaucoma surgery (MIGS) procedure. I also would not fail to implement newer means of early glaucoma detection such as corneal hysteresis, patterned electroretinographic techniques, and ganglion cell complex thickness analysis of the macula on OCT. I would implement selective laser trabeculoplasty as a first-line intervention. My biggest question of 2018 pertains to clinical trials and why intracameral moxifloxacin endophthalmitis prophylaxis is not currently practiced uniformly. Even though it was not a prospective randomized trial, the data from Hariprya et al¹ is hugely convincing in addition to many other retrospective trials to date. There is even more evidence to come.”

In 2019, I want to become proficient with topography-guided LASIK and PRK for irregular corneas. My biggest question from 2018 continues to be: Why
does normal tension glaucoma exist, and how can we safely treat it?”

I look forward to gaining more expertise with the Rx Light Adjustable Lens (RxLAL; RxSight) technology, which gives us the option to postoperatively adjust IOL power. I have been implanting the RxLAL for more than 10 years, since it was known as the LAL from Calhoun Vision, and I believe this technology will gain much more widespread attention after FDA approval. For the treatment of presbyopia, I will likely continue to implant a small-aperture IOL with extended range of focus and do so bilaterally (after it is first implanted in the nondominant eye). When it comes to corneal procedures, I will probably use photorefractive intrastromal CXL (PiXL) to a larger degree in low myopes and figure out the therapeutic range of this procedure. A note on glaucoma surgery: The number of MIGS procedures and the problems that have arisen with one of the devices (see below) are reminders that there is not yet a clear frontrunner in this field. It will be interesting to acquire skills for new devices like the InnFocus MicroShunt and see how results measure up against the (more or less) established procedures. A big question from 2018 surrounds the complete withdrawal from the market of the CyPass Micro-Stent (Alcon) by the manufacturer. Data have shown statistically significant endothelial cell loss after implantation compared to a control group that underwent cataract surgery alone. This is something of an earthquake for the surgical community. A lot of questions remain unanswered: What are we going to do with those patients who received a CyPass? Should we explant the device in all cases as a precautionary measure? What is the medicolegal situation? Who bears the financial responsibility? Are patients entitled to some compensation, and the surgeon to reimbursement for follow-up procedures? Also, in the promising field of laser cataract surgery, there is an urgent need for progress. We need new and better software, like the ability to perform primary posterior laser-assisted capsulotomy as a preventive measure against posterior capsular opacification. Sometimes it seems to me that the train of innovation in this field has unfortunately slowed down.”

Working collaboratively to bring the benefits of refractive surgery to more patients requires a cultural change on several fronts. Many of our own colleagues in ophthalmology are not aware of our current capabilities. We must develop better ways to reach them. Having those in refractive surgery move away from market share to work together on market growth is also challenging. My goal is to demonstrate the benefits of collaboration for every stakeholder to grow the field. One of my biggest questions in 2018 is the impact that topical drops will have on procedure volumes for presbyopia correction. The advent of drops to address the symptoms of presbyopia holds great promise. I anticipate it will cause many patients to become aware for the first time of the possibility to treat presbyopia. This will lead to engagement with ophthalmologists, education about presbyopia treatments, and eventual acceptance of surgical intervention as presbyopia advances. Markets such as South Korea have led the way in surgical treatments of presbyopia to great success. Topical drops may spur the same growth and acceptance in the United States.”

I am extremely interested in improving our patients’ results with their premium lenses in 2019. By using more extended depth of focus lenses this past year, we have raised postoperative quality of vision to a new level. As we continue to use and learn more about this technology, I look forward to delivering an even better patient experience. Here is my biggest question of 2018: How do we continue to reduce the risk of infection after surgery?”