EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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36 EW FEATURE February 2011 Cataract challenges July 2013 Preplanning works best with dense cataracts by Vanessa Caceres EyeWorld Contributing Writer AT A GLANCE • Treatment for dense cataracts requires preop preparedness, with instruments ready in the OR should you need to change your surgical approach to ECCE or SICS. • The use of trypan blue and dispersive viscoelastic material can make dense cataract surgery somewhat easier to manage. • Surgeons should have a low threshold to use a capsular tension ring to make sure the lens is well centered. • Monitor the case to avoid the risk for phaco wound burn. Surgeons share pearls and best techniques for dense cataracts W hen removing dense cataracts, you'll want to approach them as if you work in disaster preparedness. "I always tell others in the OR to have the fire trucks on the runway," said Dianna Bordewick, MD, Bay Care Clinic, Green Bay, Wis. "We have everything ready in the OR ahead of time to make conversion to another approach easier. We start with phaco but have a backup plan, which is manual small-incision cataract surgery [MSICS]." "Having a microinstrument set like from MST [MicroSurgical Technology, Redmond, Wash.] ready is essential for when cases take an unexpected turn," said Jeff Pettey, MD, assistant clinical professor, University of Utah, Department of Ophthalmology and Visual Sciences, and in practice, John A. Moran Eye Center, Salt Lake City. "I plan for the worst and also have capsular tension rings [CTRs], iris retractors, capsule hooks, and capsular segments in the room," added Dr. Pettey. Although dense cataracts present challenges, surgeons have some techniques and pearls to share to make management a little easier. Getting started It may be standard to start with phaco, but cataract surgeons aren't shy about switching to SICS or extracapsular cataract extraction (ECCE) when necessary for dense cataracts. "I have a low threshold to convert," said Dr. Bordewick. "If there's a high probability that I'll need too much phaco energy or may need to convert to SICS, I'll sometimes do the manual incision first but not open the incision. Then I'll go to clear cornea, but I'm ready to go should I need to convert." Dr. Bordewick noted that she rarely uses ECCE anymore, although traditionally, ECCE has been an option for approaching dense cataracts. Bilateral dense cataracts Use of the UltraChopper tip (Alcon, Fort Worth, Texas) with phaco is helpful with dense cataracts, said Dr. Pettey. "The UltraChopper has simplified our technical approach to dense mature cataracts. Even early residents find this a comfortable option," he said. Dr. Pettey will use SICS as necessary. "The sutureless SICS procedure is brilliant for the truly rock-hard nuclei where the required phaco energy compromises the health of the endothelium," he said. Eva C. Kim, MD, Kaiser Permanente, Santa Clara, Calif., converts to ECCE if it's an ultramature cataract, although with other dense cataracts she will try phaco first and also use the UltraChopper. "I tend to make the rhexis bigger in a dense cataract than I would for a typical case. I don't want to struggle when I'm taking the pieces out. I might aim for 5.5 to 6 mm instead of 5 to 5.5 mm." She will hydrodissect and viscodissect to keep the nucleus smoothly lubricated and turning in the bag so as to not destruct the zonules. For phaco fluidic settings, Dr. Pettey will start with a lower bottle height until he is certain that the zonules are intact. "I then proceed with the UltraChopper with conservative sculpt settings—bottle height 95, aspiration 25, vacuum 150, and 25% to 40% phaco power torsional and longitudinal," he said. Dr. Bordewick explains her approach with fluidic settings. "I increase the phaco power a little bit," she said. "If I have any concerns about the integrity of the capsule, I may lower the settings and the bottle as well. Sometimes I'll use a chop technique instead of divide and conquer to minimize the amount of phaco I use." Some key pearls In addition to technique and fluidic settings, there are a few other important pearls to make dense cataract removal go smoothly. Staining with VisionBlue (trypan blue, DORC, Zuidland, the Netherlands) makes it easier to visualize the capsule, Dr. Bordewick said. Dr. Pettey also uses trypan blue as needed. He'll then approach with a soft-shell viscoelastic technique and take extra care to assess for zonular stability. Copious viscoelastic in dense cataract cases makes surgical management easier as well, said Dr. Kim. "I'll have multiple Viscoats [chondroitin sulfate and sodium hyaluronate, Alcon] ready to open, sometimes even three or four. After I phaco two or three pieces, I'll coat the cornea and put it in the bag to keep the bag down," she explained. Dr. Kim advised to continue with the use of viscoelastic even if you're about ready to finish the case. That's just the time when you might Removal of a dense cataract Source: Jeffrey Pettey, MD Source: Dianna Bordewick, MD