Eyeworld

EW CATARACT 38 September 2018 YES connect by Liz Hillman EyeWorld Senior Staff Writer ous is necessary before implanting an IOL in order to leave the eye with a round pupil and reduce the risk of cystoid macular edema and other complications. The first thing to do when vit- reous presents itself intraoperatively is to stop and take stock of the sit- uation, leaving in any instruments already in the eye, Dr. Hovanesian said. "You want to have flow natural- ly moving from the anterior cham- ber to the posterior segment, so if you've got a phaco needle in the eye and you've got irrigation on, that's usually good," he explained. "You should leave it on until you can exit the eye. Often, putting a second instrument through a side port allows you to infuse fluid or visco- elastic before removing the phaco instrument or whatever instrument is in the main incision. That keeps the positive pressure, and it prevents unnecessary movement of vitreous forward." Proper planning and practice can result in positive outcomes T here's a saying that "the only surgeon who doesn't have complications is the one who doesn't operate." It's a saying that John Ho- vanesian, MD, Harvard Eye Associ- ates, San Clemente, California, cites, especially as it applies to complica- tions during cataract surgery that might require anterior vitrectomy. "Every surgeon needs to have some basic vitrectomy skills in order to handle what may arise in the operating room," Dr. Hovanesian said. "It's a skill that we think of with a little bit of dread because of the situations where it arises, but it's something we can't wish away." The most common need for anterior vitrectomy occurs when the posterior capsule is opened, inad- vertently, during cataract surgery and vitreous presents itself into Preparing for anterior vitrectomy D ealing with vitreous is a part of life for every anterior segment surgeon. The most common situation neces- sitating an anterior vitrectomy is a ruptured posterior capsule during cataract surgery; in a split second the case can go from "great" to "complicated." In many residencies, when the capsule is broken, an attending or fellow will take over and perform the anterior vit- rectomy. As a result, many young surgeons have seen several anterior vitrectomies but have not performed the procedure them- selves until they are out of training. In this month's "YES connect" column, John Hovanesian, MD, Charles Weber, MD, and Nicole Fram, MD, discuss their approach to planned and unplanned anterior vitrectomies. It is important for the surgical team to have the vitrectomy equipment in an easily accessible location and to know how to set it up to minimize stress and disruption during the case. By being prepared for this, and following the excellent advice in this column, young eye surgeons can succeed in these stressful cases and still achieve excellent outcomes for their patients. David Crandall, MD, YES connect co-editor the capsular bag or anterior cham- ber, Dr. Hovanesian said. Charles Weber, MD, EyeHealth Northwest, Portland, Oregon, and adjunct as- sistant professor, Moran Eye Center, University of Utah, Salt Lake City, said the most common situations to necessitate anterior vitrectomy in his practice are subluxated and dislocated lenses. "These cases might already have vitreous presenting to the anterior segment preoperatively, vitreous presenting anteriorly intraoper- atively, or a high enough risk of postoperative vitreous prolapse to necessitate vitrectomy," Dr. Weber explained. Nicole Fram, MD, Advanced Vision Care, Los Angeles, said that while the unplanned situations that require anterior vitrectomy are stressful, understanding the basic principles of how to handle these cases will improve patient safety and help ensure a positive result. In any case, Dr. Hovanesian said thorough cleaning up of vitre- Anterior vitrector used to remove residual Soemmering's ring near the completion of an IOL exchange following secondary IOL placement via double-needle intrascleral haptic fixation. Note the lower cut rate. Source: Charles Weber, MD

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