Eyeworld

ract surgery. The number of doses required following cataract surgery is high, and it can be a burden for patients to keep track of. There is a new era of being able to deliver drugs at the time of cata- ract surgery, Dr. Matossian said. She mentioned a number of methods. The first was transzonular injec- tion, but Dr. Matossian noted this is not FDA approved and there is a learning curve. Pars plana injection is another option, but Dr. Matossian pointed out that this is an addition- al step, there is a learning curve, and there is some pain. Dr. Matossian mentioned intracameral products, which are a familiar landscape, require no addi- tional instruments, and are quick. However, the problem is they're not FDA approved. Dr. Matossian mentioned two FDA-approved products: Dexycu (dexamethasone intraocular suspen- sion, EyePoint Pharmaceuticals, Wa- tertown, Massachusetts), which can be administered over a 30-day peri- od, and Dextenza (dexamethasone ophthalmic insert, Ocular Therapeu- tix, Bedford, Massachusetts). Editors' note: Dr. Donaldson and Dr. Matossian have financial interests with a number of ophthalmic companies. Cataract surgery complications: "You make the call" A session featured a variety of com- plicated cataract surgery case videos, with audience members and panel- ists weighing in on how they would handle different aspects of the case. David Chang, MD, Los Altos, Cali- fornia, moderated and presented the video cases. The first panel consisted of Florian Kretz, MD, Heidelberg, Germany, Kerry Solomon, MD, Mt. Pleasant, South Carolina, Jay 7. Define the goal, delegate, and lead. Refractive IOLs and femto laser- assisted cataract surgery Preeya Gupta, MD, Durham, North Carolina, presented on manual vs. femto arcuate incisions. She noted that 52.5% of patients with cataracts have more than 0.75 D of clinically significant preexisting corneal astig- matism. For preop planning, Dr. Gupta highlighted three main steps: make sure the astigmatism is regular (avoid irregular astigmatism), rule out any confounding corneal pa- thology (avoid in ABMD, Salzmann's nodules, pterygium), and plan treat- ment based on a nomogram (always make the incision on the steep axis). Dr. Gupta shared reasons why surgeons may switch from manual to femto incisions. Femto corneal incisions have precise depth and placement, continuous curvature, and offer the ability to titrate the incision, which does not disrupt the epithelium and you can open the incision after surgery. Dr. Gupta also mentioned some of the key differences between femto and manual incisions. Femto is pho- todisruptive (the incision architec- ture is different from manual); you can't use the same nomograms (you will get overcorrection if using a manual nomogram with femto); and centration is the most critical step in femto because decentration can be an issue. Dr. Gupta said there is not enough evidence to say one is better than the other at this point. Howev- er, her personal preference is to use the femtosecond laser to create an incision because it offers increased efficiency at the time of cataract surgery; it's more predictable in her hands; and it makes her think about treating astigmatism in all cases. In summary, Dr. Gupta said that the femtosecond laser and the manual technique are both excellent options for creating arcuate incisions in astigmatism correction. Editors' note: Dr. Gupta has financial interests with a number of ophthalmic companies. IOL fixation without capsular support and learning the Yamane technique Brandon Ayres, MD, Philadelphia, discussed options for IOL fixation without capsular support. He shared tips for using iris fixation, which he said is helpful to fixate a three-piece IOL and is minimally invasive. He said a 10-0 polypropylene suture on a curved needle is best and recommended passing the suture "into the curve" of the haptic, which will help gather the iris. The suture can be tied with a McCannel or Siepser sliding knot. Though safety has been estab- lished with iris fixation, it is not without difficulty and complica- tions, he said. Issues like ovalization, hemorrhage, macular edema, and repeat dislocation could occur. Dr. Ayres also discussed scleral suture fixation. The use of Gore-Tex sutures and IOL are off label. Suture fixation gives excellent four-point stability, he said, but you must not overtighten the suture. Knots must be buried into the sclera to avoid exposure. Dr. Ayres added that hy- drophilic acrylic material can lead to problems. Lastly, Dr. Ayres highlighted haptic fixation. He said to mea- sure twice and make sclerotomies once. You must use a thin-walled, 30-gauge or 27-gauge needle. He said one should watch the oxygen when using cautery. Also during the session, Zaina Al-Mohtaseb, MD, Houston, shared pearls for learning the Yamane dou- ble-needle technique. • Use a special large lumen 30-gauge needle. • Place the needle on a non-luer locked TB syringe filled with bal- anced salt solution (not too tight). • Test the haptics in the needles prior to lens insertion. • An AC maintainer can be helpful, especially in vitrectomized eyes. • Mark the conjunctiva at 1 and 7 o'clock (exactly 180 degrees apart) 2 mm posterior to the limbus. • Stabilize the globe using a 0.12 near area of needle insertion. • Insert the needle a bevel and a half (2 mm) in the sclera prior to turning centrally. • Bend 25-gauge MaxGrip forceps. • Use low-temp cautery to create flanged haptic. • You can use any three-piece lens, but the haptics' angle and ends differ. • Grab the proximal haptic parallel instead of perpendicular. Editors' note: Dr. Al-Mohtaseb and Dr. Ayres have financial interests with a number of ophthalmic companies. Complicated cases Kendall Donaldson, MD, Plan- tation, Florida, discussed how to handle soft cataracts. Some of the "dangers" of soft cataracts include inability to crack or chop easily, bowling out the nucleus, creation of a posterior sheet of residual lens material, false confidence, and high expectations. Dr. Donaldson suggested consid- ering a slightly larger capsulotomy, allowing flip and carousel. She also said that changing your second in- strument to use a Drysdale nucleus manipulator or Koch spatula could help. She said not to pre-judge based on the size of the cataract. Cynthia Matossian, MD, Doylestown, Pennsylvania, pre- sented on alternative drug delivery options for cataract surgery. Compliance is a major issue. Around 93% of patients improperly administer drops following cata- 93 EW MEETING REPORTER continued on page 94 March 2019

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