Eyeworld

EW CATARACT 29 August 2018 very small and the lens may dis- lodge. In the postop months in such patients Dr. Devgan looks for exces- sive contraction on the capsule. If that occurs, he performs a YAG laser of that anterior capsule to break the phimotic ring. Another long-term precaution is to watch for progressive zonu- lar weakness, which could allow a complete dislocation of the lens and capsular bag into the vitreous. "This patient had a beautiful outcome," Dr. Devgan said. "It showed that with proper planning and certain techniques we can do a beautiful job on patients with pseu- doexfoliation, and it's not too much of a burden for us." EW Editors' note: Dr. Devgan is a principal in www.IOLcalc.com and www.CataractCoach.com. Contact information Devgan: Devgan@gmail.com Intraop techniques Dr. Devgan used bilateral choppers to manually and gently stretch the pupil. However, surgeons should be careful to avoid contact with the an- terior capsule during the maneuver. He used a technique to bring the nucleus out of the capsular bag and tilt it into the iris plane so that the iris sphincter held it in place. This approach required a capsulor- hexis of at least 5 mm in diameter, however, the pupil size was just 4 mm. He injected viscoelastic at the pupil margin to help push the iris and expand the pupil, which is a technique Robert Osher, MD, has called viscomydriasis. "We can then make the capsu- lorhexis right at the pupil margin or, even better, just underneath it," Devgan said. "Most experienced surgeons can make the capsulor- hexis larger than the pupil without directly visualizing it." Dr. Devgan used balanced salt solution to hydrodissect the nucleus out of the capsular bag and tilt it into the iris plane. The iris sphinc- ter held the nucleus in place while he used a phaco chop technique to emulsify and aspirate it. "This technique brings the nucleus out of the capsular bag in order to minimize stress on the zonules," Dr. Devgan said "Even in cases in which there is zonular laxity, this supracapsular technique can be safer than intracapsular tech- niques such as divide and conquer." Due to the shallowness of the anterior chamber, Dr. Devgan per- formed as much of the phacoemulsi- fication as possible at the iris plane. Another key to good outcomes in this patient was to ensure that the zonules were secure when he removed the cortex. That involved watching the edge of the capsulor- hexis during cortex removal for any signs of movement in the capsule or capsulorhexis. "Take your time on this part; it should be done in slow motion even," Dr. Devgan said. A full instructional video with narration of this case can be seen at www.CataractCoach.com. Postop keys Dr. Devgan added preservative-free triamcinolone (0.5–1 mg) in the an- terior chamber at the end of surgery to quell the inflammation. Due to weak zonules, patients with pseudoexfoliation face the risk of capsular phimosis in the months or even years postop. When nor- mal capsule contraction occurs, the opening in the capsule can become

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