Eyeworld

79 November 2018 EW MEETING REPORTER The other critical element of modern cataract surgery at the time was where the posterior cham- ber lens would be implanted, Dr. Neuhann said. It would either be implanted in the ciliary sulcus (the most common) or into the capsular bag. The turning point for Dr. Neu- hann was when his mentor, Richard Kratz, MD, suggested a transition to in-the-bag implantation but the current technique, can-opener, proved to be an obstacle to this. Dr. Neuhann realized he would either have to find a solution or stay in the sulcus. Dr. Neuhann began to ex- plore different techniques, visiting renowned capsular bag implant surgeons. Theoretical considerations were important. The lens capsule is comparable to cellophane, so a con- tinuous anterior capsular margin, closed in itself, would be a solution. A case he encountered in the fall of 1984 spurred him to produce his capsulorhexis technique because the can-opener technique failed for his patient with retinitis pigmentosa because her zonules were so loose. Howard Gimbel, MD, was working on a similar principle at the time. Dr. Neuhann stressed that the term "capsulorhexis" refers to the technique and the process "to tear" rather than cutting. He added that it's now rec- ognized that he and Dr. Gimbel "invented" the basic principle simultaneously and independently from each other, using technical approaches somewhat different in detail. Dr. Neuhann said that the technique used today of the circular capsulorhexis is based on his variant of the common basic principle and first described in scientific literature. Video symposium on surgical complications In a video symposium, Michael Amon, MD, Vienna, Austria, shared a case of a late onset Argentinian flag. The patient had a mature white cataract with a 4+ nucleus, and Dr. Amon put trypan blue under OVD. Early in the case, Dr. Amon en- experience with this technology, Burkhard Dick, MD, PhD, Bo- chum, Germany, noted that small aperture IOLs reliably achieve this goal without splitting light. Visual acuity is excellent, and the lens can compensate for deviations in target refraction and residual astigma- tism. These lenses give high quality distance vision and cause no change to binocular contrast sensitivity, he said. They also do not encumber retinal visualization, and patients are satisfied with the outcomes. Monovision remains an ex- cellent option to achieve spectacle independence and is not a "cheap multifocal," according to Ehud Assia, MD, Tel-Aviv, Israel. The surgeon does not need to decide to carry through monovision during the first surgery, said Dr. Assia, who achieves optimal results with –1.75 D. He thinks that it is slightly less effective than multifocal IOLs but has fewer adverse effects and high patient satisfaction. His overall personal approach involves: trifo- cals if the patient desires spectacle independence, although photopic phenomena are expected; EDOF or low monovision (about 1.0 D) if the patient wants spectacle indepen- dence with a priority for intermedi- ate over near vision, or if the eye is not ideal; and he aims for emmetro- pia in the first eye, irrespective of dominance, if the patient does not want a MFIOL or is unable to afford one. When the UCVA is good, he recommends setting the second eye for near, even if the patient does not ask for near vision correction. The capsulorhexis The ESCRS Heritage Lecture was given by Thomas Neuhann, MD, Munich, Germany, and highlighted the invention and evolution of the capsulorhexis. He looked back to techniques in the 1970s and 1980s. One critical step, he said, was the technique for anterior capsulectomies: can-opener, letter box, or Christmas tree. The can-opener was the most adopted because it opened the capsule in circular fashion and had a controlled diameter. France, opened the extended depth of focus (EDOF) symposium with a discussion of optical principles. EDOF are designed to provide a range of visualization rather than a single focal point and result from progress in optics and better un- derstanding of vision quality. Dr. Cochener made the case for contrast sensitivity, explaining that stretch- ing the visual range would ultimate- ly come at the price of contrast. Both additive and subtractive technologies can result in an EDOF cornea, according to a presentation given by Roberto Bellucci, MD, Verona, Italy. Corneal inlays are indicated unilaterally and are more difficult to center than presbyLASIK, requiring closer follow-up. PEARL (PrEsbyopic Allogenic Refractive Lenticule) is a promising technique to achieve an EDOF cornea. Bilateral presbyLASIK techniques are "heavi- er" in the non-dominant eye and have good published results. Dr. Bellucci explained that selecting the appropriate procedure should be tai- lored to the patient's character and needs, however, bilateral asymmetric central presbyLASIK is his preferred approach. Another option that has been successfully implemented to extend the depth of focus is the use of the small aperture IC-8 IOL (AcuFocus, Irvine, California). Discussing his switched to using a blunt instru- ment because he was very near to the posterior capsule at this time, and it was then that he began to realize that things were not going very well. Dr. Feijoo realized that the capsule was probably broken. He re- tracted his instruments very quickly, causing the nucleus to drop. After this, he tried to ensure that the anterior segment was free of vitreous. Dr. Feijoo said that he knew the patient would have to be referred to a retina specialist and the surgery would not be complete at the end of the operation. He used preservative-free triamcinolone to both ensure there was no vitreous coming forward and to help with inflammation in the postoperative period. Dr. Feijoo said he proceeded by injecting the IOL into the ciliary sulcus. This may be a controversial choice, he admitted, but if it's in place, it ensures some separation between the anterior and posterior chamber. After showing the case, Dr. Feijoo stressed the importance of avoiding hydrodissection in these cases. Now, he prefers to use hy- drodelineation. The many sides of extended depth of focus Beatrice Cochener, MD, PhD, Brest, continued on page 80 View videos from the 2018 ESCRS: EWrePlay.org Nick Mamalis, MD, describes the progress in developing a technology for IOL modification.

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