Eyeworld

I CHALLENGING CATARACT CASES N FOCUS 56 | EYEWORLD | SEPTEMBER 2019 Contact information Al-Mohtaseb: zaina1225@gmail.com Gayton: jlgayton9@gmail.com Kang: pkang@edow.com Katsev: katsev@aol.com Raviv: tal.raviv.md@gmail.com Visco: dvisco@eyesofyork.com by Vanessa Caceres EyeWorld Contributing Writer practicing with the miLOOP first on less dense cases so that it can be visualized. Dr. Gayton said to proceed with caution when using the miLOOP in dense cases with little to no cortex. "You can perforate or tear the capsule and/or disinsert zonules," he said. For nuclear disassembly of a mature bru- nescent case, make a deep groove, and be sure to hydrodissect to allow the lens to split easily, Dr. Katsev advised. Dr. Al-Mohtaseb shared four pearls for nuclear disassembly: • Widen the initial groove when sculpting. • Use the stop-and-chop technique to decrease ultrasound energy usage • Use the Nagahara phaco chopper to chop the lens into small pieces as much as possible, then use phaco to remove the pieces. • Phaco in the capsular bag as much as possible. D ense white cataracts and mature brunescent cataracts can make surgery particularly challenging, yet the reward comes once patients can see again. "Patients with bilateral brunescent cataracts are typically at hand motions and are the happiest of patients [after surgery]. They go from being unable to live alone to being able to drive," said Zaina Al-Mohtaseb, MD. EyeWorld spoke with several seasoned sur- geons to find out how they manage these types of cataracts. Mature brunescent cataracts A higher risk of complications and difficult visualization are two challenges associated with mature brunescent cataracts. Mature cataracts can be dark brown, red, white (with or with- out a liquid component), or black, said Johnny Gayton, MD. "Many of the mature cataracts have a leathery plate at the bottom that makes cracking difficult," Dr. Al-Mohtaseb said. "In addition, there is very little cortex and thus less protec- tion of the posterior capsule." Trypan blue can help to visualize the capsule, which is often hard to see, and a deep phaco groove allows for a quicker procedure, said Doug Katsev, MD. Use of a femtosecond laser with mature brunescent cataracts is potentially helpful to soften the lens nucleus and results in less ultrasound energy use for lens removal, Dr. Al- Mohtaseb said. Dr. Katsev said that the femto laser can help in using less energy, but he does not think its use is a must. One device that some surgeons have found helpful is the miLOOP (Carl Zeiss Meditec), which provides energy-free lens fragmentation. This is especially helpful for cataracts with a dense, leathery plate, Dr. Al-Mohtaseb said. "It helps crack the lens, which is one of the hardest parts in phacoemulsifying these dense cases. There is a short learning curve and the device is very helpful," she said. She recommended Better management of brunescent and dense white cataracts At a glance • Both mature brunescent cataracts and dense white cataracts present with unique surgical challenges. • The femtosecond laser can potentially help with both types of cataracts, but surgeons should keep in mind the lim- itations of the laser and follow their personal comfort level. • Provide patients, even those with dense white cataracts, with all possible IOL and astigmatic correction options. continued on page 58 White cataract with a planned toric; a round complete capsulotomy is critical to refractive success Source: Tal Raviv, MD

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