EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/78710
May 2012 matous eyes and not the result of an acute vascular event is supported by studies that show a very strong associ- ation between the hemorrhages and visual field change, according to Gus- tavo de Moraes, M.D., New York. Of particular interest, he said, is that both seem to occur in the same location. "In glaucomatous eyes, spatially consistent, localized visual function loss precedes the onset of disk hemorrhage," Dr. Moraes said. "Sustained localized progression continues at the same location after the disk hemorrhage." Because of this finding, Dr. Moraes advised that clinicians photograph the optic disc regularly to monitor changes. "Ideally you would do that twice a year," he said. He also noted that finding a disc hemorrhage early might help with therapy. "Once you have a disc hemor- rhage, be more aggressive in your therapy, and it slows the rate of progression," he said. Editors' note: The doctors mentioned have no financial interests related to their comments. New paradigms, innovative techniques In just two out of their first 50 cases of cataract surgery performed with the femtosecond laser, Tim Roberts, M.D., Sydney, Australia, and his col- leagues, encountered what was, at the time, something completely new: intraoperative capsular block syndrome. Dr. Roberts presented one of those cases at a Cataract Grand Round conducted by the Interna- tional Council of Ophthalmology. During the surgery, after the femto laser incisions were completed and Dr. Roberts was initiating hy- drodissection, he was surprised by a pupil snap, signaling posterior cap- sular rupture. An image of the dropped lens— complete with gas bubble on the anterior surface beneath the still-at- tached anterior capsule—accompa- nies the publication of the case. What's interesting—and signifi- cant—about this case, said Dr. Roberts, is that it shows that the laser did exactly what it was meant to do, but that cataract surgery had shifted into a new paradigm. What intraoperative capsular block syndrome represents, he said, is what is encountered whenever a new technology is introduced: a completely different (intraocular) environment. That said, the result of misman- aging that "new" environment does echo what cataract surgeons—even those performing standard phaco— experience very much in the here and now: dislocated IOLs. For whatever reason, cases of dislocated IOLs appear to be increas- ingly commonplace, said Abhay Vasavada, M.D., Ahmedabad, India. He recommended a stepwise strategy that includes assessing the position of the IOL, assessing the residual cap- sular support, getting a pre-op retinal opinion, thorough counseling, and knowing the type of IOL involved. Dr. Vasavada demonstrated his approach using a modified injector to retrieve the dislocated IOL. The IOL retrieval mechanism, developed by one of Dr. Vasavada's colleagues, can be made by any surgeon follow- ing instructions that can be found online. Speaking of capsular support, Y.C. Lee, M.D., Perak, Malaysia, demonstrated his preferred tech- nique for sclerally fixating an IOL in a case with insufficient capsular sup- port—without using sutures or glue. Dr. Lee's technique involves ex- teriorizing the IOL's haptics through tiny sclerotomies and then inserting them into scleral tunnels made using a slightly curved small-gauge needle. Sutures are, in fact, used, but rather than anchoring the haptics, they simply stabilize the scleral fixa- tion. Dr. Lee emphasized that in a re- view comparing various approaches to scleral fixation—with or without sutures or glue—it's been found that the technique matters less than sur- gical skill, experience, and comfort with whatever technique is used. Editors' note: Drs. Roberts and Lee have no financial interests related to their comments. Dr. Vasavada has financial interests with Alcon (Fort Worth, Texas). "Very important that blindness be addressed" While developed parts of the world are rapidly trying to improve the premium experience of cataract sur- gery, such as the latest in lens and laser designs, Sanduk Ruit, M.D., Kathmandu, Nepal, and colleagues are using a simple, low-cost extra- capsular procedure to help eradicate blindness in the mountains of Nepal and beyond. "There is an extreme inequity in terms of quality and quantity [in de- veloping areas]. It's very important that blindness be addressed," Dr. Ruit told the audience during his Lim Lecture. Dr. Ruit, co-founder and director of the Himalayan Cataract Project, uses a manual, sutureless, small inci- sion extracapsular procedure, called manual small incision cataract sur- gery (SICS), on patients he described as deprived socially, economically, and hard to reach geographically. Because teams have to be em- ployed in remote locations, some- times only accessible by foot, the surgery needs to be simple and effec- tive, which is the case with SICS. In the afternoon Challenging EW MEETING REPORTER 59 Cases session, Zaheer ud Din Aqil Qazi, M.D., Karachi, Pakistan, gave the Susruta Lecture, which recog- nizes contributions to cataract sur- gery, giving priority to clinicians who have contributed to the control of mass cataract blindness. Dr. Qazi's lecture, "High Volume, High Quality, Low Cost Cataract Surgery," focused partly on how his hospital, the LRBT Free Eye Hospital, tries to minimize endothe- lial cell loss in the many cataract surgeries performed there. Endothelial health cannot be determined by routine slit lamp evaluation unless there are guttae or Fuchs' dystrophy, and routine specu- lar microscopy cannot be performed in every cataract case, Dr. Qazi noted. "Endothelial trauma done dur- ing surgery becomes apparent after 5-6 hours of surgery," he said. "The latest [phaco] tip designs have helped a lot in minimizing trauma and completing the procedure in the shortest time." Editors' note: Drs. Qazi and Ruit have no financial interests related to their comments. continued on page 60 Astigmatism correction with the femtosecond laser A new application for astigmatic correction is now available on two femtosecond lasers, according to a presentation at an Abbott Medical Optics (AMO, Santa Ana, Calif.)-sponsored breakfast symposium. The iFS and FS60 platforms (AMO) will perform arcuate incisions with no hardware or software purchases required. Instead, surgeons will need to upgrade the software for the two different lasers. The advantages of the femtosecond method give the surgeon full control of customizable parameters, including choosing between intrastromal and penetrating incisions, as well as deciding on incision depth, arc length, and side cut angles. It only takes three steps to do the procedure: select the anterior side cut, enter the parameters, and decide whether to go intrastromal or penetrating. Although further nomogram refinement is required, Noshir Shroff, M.D., New Delhi, India, said preliminary results from femtosecond AK procedures show that it can safely reduce low levels of astigmatism. So far, penetrating incisions seem to be more powerful than intrastromal cuts. Predictability of the femtosecond incisions appears to be improved over manual techniques. Incisions with the femtosecond laser are more precise compared to diamond blades, Dr. Shroff concluded. Editors' note: This event was sponsored by AMO.