Eyeworld

EW MEETING REPORTER 76 December 2018 EyeWorld/ASCRS reports from the 2018 AAO Annual Meeting, October 26–30, Chicago advent of extracapsular surgery and phaco that we wanted to maintain strong zonules to support an IOL, he said, adding that phaco is challeng- ing with weakened zonules. Viscoelastic devices allow phy- sicians to maintain a stable cham- ber, Dr. Cionni said. Additionally, capsulorhexis, hydrodissection, and the advent of the femto laser have aided in these challenging cases, as do capsular hooks and tension rings. Dr. Cionni shared some of the general principles of zonular man- agement: • Never let the chamber collapse. • Complete the CCC (make it larger than normal to be able to manipu- late the nucleus more easily). • Use generous hydrodissection. • Use generous OVD for expanding the capsular bag and manipula- tion of the nucleus and cortex. • Use stable-chamber phaco and I&A techniques. • Hooks, rings, and segments are very valuable. Dr. Cionni highlighted when a CTR is required and at what point during the procedure it should be placed ("as late as you can but as soon as you need it"). He discussed the advent of his Cionni ring, as well as modifications other surgeons have made to his ring. Dr. Cionni noted that over time, he has learned the Prolene sutures are no longer recommended (and he has spent would have been crucial to find it because he had dealt with another case where a sliver of the original lens after an IOL exchange was left in the eye and caused corneal de- compensation. Dr. Hoffman concluded by of- fering key tips from this case. If the IOL won't center, it's usually from haptic damage. But it could also be caused by capsular bag or zonular compromise or vitreous prolapse. If you have a torn haptic or missing piece, you want to find and remove the fragment, or document that the fragment was never injected into the anterior chamber. Editors' note: Dr. Hoffman has finan- cial interests with Alcon (Fort Worth, Texas) and MicroSurgical Technology (Redmond, Washington). Managing weak zonules Robert Cionni, MD, Salt Lake City, gave the Kelman Lecture on "Deal- ing with Damaged Zonules." There's no doubt that when challenged with weakened zonules, we have an unmet need, he said, adding that 20 years ago, there was a tremendous unmet need. In ancient times, when couch- ing was the preferred method for cataracts, weak zonules were a blessing because you could drop the nucleus into the back of the eye, Dr. Cionni said. It wasn't until the Editors' note: Drs. Hill, Holland, Lindstrom, and Osher have financial interests with various ophthalmic companies. Cataract complications A spotlight session focused on a vari- ety of cataract complications, with presenters sharing videos of issues they encountered. Cases examined posterior polar cataracts, white cat- aracts, zonular dialysis, wrong IOL power, shallow anterior chamber, and more. Richard Hoffman, MD, Eugene, Oregon, shared a case where he had problems with a decentered lens. He presented a bimanual case where he injected an IOL with no resistance. The lens was centered at the end of the procedure, but at postop day 1, he noticed that the IOL was decentered in the bag, despite the patient being asymptom- atic. Thinking it would be an easy fix, Dr. Hoffman reopened one of the bimanual incisions and reposi- tioned the lens. However, he noticed that it still wasn't centering. He then decentered the lens temporally so it would slide back into a central position when it decentered. Still not satisfied, Dr. Hoffman rotated the lens 90 degrees, and as he was rotating, he noticed that something was "not quite right." The problem, he said, was that half of the haptic was missing. He used intraocular scissors to remove the lens, ultimately going through the main incision. He took the lens out without difficulty but could not find the missing piece of the haptic. Dr. Hoffman removed the visco- elastic, doing a meticulous 5-minute removal in hopes of finding the missing haptic fragment. However, he still couldn't find it. Dr. Hoffman then injected viscoelastic and placed a three-piece lens in the bag. The lens was inserted with no problem, and he removed the viscoelastic (and was still unsuccessfully trying to find the haptic fragment). After referencing the original surgical video, Dr. Hoffman realized that the fragment was either left in the injector or never came with the lens (but it was not in the eye). Dr. Hoffman stressed that if the fragment had been in the eye, it View videos from the AAO Annual Meeting: EWrePlay.org Bonnie Henderson, MD, discusses medication prophylaxis for cystoid macular edema and endophthalmitis in routine cataract surgery. Sponsored by

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