EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/146899
July 2013 EW RESIDENTS 53 with pseudoexfoliation" From left to right: Peter Brennen, MD, Matthew Kaufman, MD, Anya Gushchin, MD, Joel Schuman, MD, FACS, Jake Waxman, MD, PhD, Jessica Kovarik, MD, Carlos Medina, MD, and Angela Elam, MD Source: Matthew Kaufman, MD capsular tension ring (CTR) placed at the time of the original surgery. These have been shown to decrease the rate of IOL dislocation in cases with weak zonules.2 We debated whether this meant that surgeons are not using a CTR often enough in patients with PXF. We searched the literature and were unable to find a prospective study comparing in-thebag IOL dislocation rates in PXF pa- tients with and without a CTR. We decided this would be a good avenue for future study. The authors acknowledge that the study suffers from limitations inherent to all retrospective studies, such as the lack of a control group. As the patients underwent surgery over a period of 22 years, the authors state that Dr. Shingleton began to favor placement of posterior chamber lenses later in the study as techniques improved. It would have been interesting to see a breakdown of the IOL exchange group results over time, as improvements in surgical equipment such as vitrectors, lenses, and viscosurgical devices may have improved outcomes and decreased complications. We would also like to have seen more discussion regarding how surgical techniques were chosen for each patient. For instance, scleral-sutured IOLs can dislocate over time as a result of breakdown of suture material, which could make this procedure less suitable for younger patients.3,4,5 Newer techniques such as the fibrin glueassisted scleral flap PCIOL procedure described by Agarwal may end up being a preferred technique.6 This is the largest series published to date comparing outcomes of IOL exchange and repositioning techniques, and we felt it provides important information regarding the improvements in vision and IOP that can be achieved with these surgeries. As results were similar across all techniques, surgeons can use these results to find a technique that works well in their hands, ultimately improving patient care. EW References 1. Drolsum L, Ringvold A, Nicolaissen B. Cataract and glaucoma surgery in pseudoexfoliation syndrome: a review. Acta Ophthalmol Scand. 2007;85(8):810-21. 2. Hasanee K, Ahmed, II. Capsular tension rings: update on endocapsular support devices. Ophthalmol Clin North Am. 2006;19(4):507-19. 3. Price MO, Price FW, Jr., Werner L, Berlie C, Mamalis N. Late dislocation of scleral-sutured posterior chamber intraocular lenses. J Cataract Refract Surg. 2005;31(7):1320-6. 4. Vote BJ, Tranos P, Bunce C, Charteris DG, Da Cruz L. Long-term outcome of combined pars plana vitrectomy and scleral fixated sutured posterior chamber intraocular lens implantation. Am J Ophthalmol. 2006;141(2):308-12. 5. Kim J, Kinyoun JL, Saperstein DA, Porter SL. Subluxation of transscleral sutured posterior chamber intraocular lens (TSIOL). Am J Ophthalmol. 2003;136(2):382-4. 6. Agarwal A, Kumar DA, Jacob S, Baid C, Agarwal A, Srinivasan S. Fibrin glue-assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules. J Cataract Refract Surg. 2008;34(9):1433-8. Contact information Waxman: waxmane@upmc.edu Go continued from page 51 optimize the fluidics of phacoemulsification to provide a higher level of safety and better visual outcomes for our patients. Donna Siracuse-Lee, MD Assistant professor, Department of Ophthalmology, Boston University School of Medicine VA Boston Healthcare System Boston Medical Center As always, good communication and preparation are key teaching tools in the operating room. 1. Before surgery, I will proactively ask the resident what he/she would like to focus on that day. I then begin with the basic principles below, giving specific examples. 1.) Maintain anterior chamber stability. a. Focus on wound construction. b. Eliminate extraneous instrument passes. c. Reduce downward pressure and stress on wounds. d. Adjust bottle height as needed, down when PC tear is suspected or detected. 2.) Aspiration brings things to the tip, therefore flow rate controls the speed of the surgery. a. Slow down early on in training, during a difficult case or with a floppy iris. b. Decrease when a PC tear is suspected or detected. c. Increase with experience and if flow/speed is not adequate. 3.) Vacuum holds material at the tip during phaco. a. Upward adjustments help while chopping or maneuvering pieces. b. Moderate for softer material. 4.) Phaco works when the tip is occluded. a. Phaco only when you have nucleus at the tip. b. Short taps with the pedal will redirect the piece. c. Listen to the machine. Clear the tip when occlusion occurs. 5.) Stay central. a. Avoid unnecessary movements. Allow the machine to do the work. b. Focus on coordination of hands and feet. 2. Before starting, I make sure the microscope is focused and centered and that the resident's hands and feet are positioned comfortably for proper coordination. 3. I avoid criticisms that lack instruction. "You are moving around too much," is not as useful as, "Stay central, rotate the tip toward your piece, and control the pedal to guide the piece in. Let the pieces come to you." 4. I teach them to adjust density settings for harder cataracts and assure them that total phaco power will go down as efficiency goes up. 5. I explain what I am doing and why. Supervisors should adjust the settings intraoperatively, but explain how to do this independently. Intraoperatively, I will say, "I am slowing you down now by lowering the aspiration flow rate"; "I am allowing you to grasp this soft lens better by switching to epinuclear settings," and review after the case. 6. I remind them that phaco efficiency is like parallel parking. Surgical finesse comes from small adjustments and will become second nature. 7. Postoperatively, I review each surgery step by step. This post-surgical discussion encourages a sense of self-improvement and fosters an understanding of phacodynamics and fluidics over time. EW Contact information Avery: bavery@salud.unm.edu Devgan: devgan@gmail.com Siracuse-Lee: donna.siracuse-lee@va.gov