Eyeworld

26 | EYEWORLD | JULY 2019 ATARACT C YES CONNECT Contact information Al-Mohtaseb: zaina1225@gmail.com Khandelwal: Sumitra.Khandelwal@bcm.edu Raju: Leela.Raju@nyumc.org Rao: naveen.k.rao@lahey.org Shah: manjool@med.umich.edu by Liz Hillman EyeWorld Senior Staff Writer There was still pigment on the anterior capsule from the synechiae, which she advised removing, otherwise it's difficult to make the capsulorhexis. After removing the pigment, Dr. Al-Mohtaseb removed the OVD (a cohe- sive) with irrigation and aspiration and stained with trypan again. She reinserted OVD and using Utrata forceps, pulled centrally with little maneuvers as she began the capsulorhexis (not circumferentially). She noted some zonular loss in this case during this step. After removing the nucleus and the cortex, she placed a capsular tension ring through the paracentesis, holding onto the ring with a Sinskey hook until it was in place. Starting out with miLOOP Leela Raju, MD, provided pearls for those start- ing out with miLOOP (Carl Zeiss Meditec). First, stain with trypan blue to visualize the capsule. Then, hydrodissect away from the areas that you're going to have the loop come out of so that you can clearly see your edge. Dr. Raju noted the black mark on the handpiece of miLOOP that serves as a guide to avoid over insertion. It might feel like you are stretching the capsule, Dr. Raju said, but it has A ttendees at a symposium sponsored by the Young Eye Surgeons (YES) Clinical Committee at the 2019 ASCRS ASOA Annual Meeting learned about the challenging cases and complications faced by the com- mittee's panelists. Here's a recap of a few of the presentations from the symposium. Anterior capsular fibrosis Zaina Al-Mohtaseb, MD, addressed creating a capsulorhexis in the presence of anterior capsular fibrosis. In cases where she is worried about zonular loss and where there is a lot of synechiae, Dr. Al-Mohtaseb said she likes using iris hooks, premarking hook locations so that her paracentesis and wound are well positioned. Capsules with anterior fibrosis are at higher risk for tearing during the capsulorhexis for- mation, Dr. Al-Mohtaseb said. In the case she shared, she inserted intracameral epinephrine, then stained the capsule with trypan blue. She irrigated it out and injected OVD and used the cannula to break the synechia and lift the iris. This step, Dr. Al-Mohtaseb said, is key to pre- vent the anterior capsule from tearing. She then inserted a Malyugin ring. Challenging and complicated cases covered in YES symposium operate on patients who have retinitis pigmen- tosa or diabetic macular edema, I might use the steroid longer," she said. With prednisolone, she always educates patients about the importance of vigorously shaking the bottle since this is a suspension, not a solution. If they're still in- flamed despite using prednisolone, she'll switch them to either the branded Pred Forte (Aller- gan) or Durezol (difluprednate, Novartis). She finds she rarely encounters problems with pressure spikes, adding, however, that these are more likely to arise with use of diflupred- nate, which she doesn't typically use unless there is a history of uveitis. In the rare instances that she encounters a pressure spike, she switches the patient to a milder steroid, if possible, and may add a glaucoma drop to control pressure. In select cases where her retinal colleagues recommend it, such as those involving pre-ex- isting CME, she does an intravitreal injection using triamcinolone acetonide. Dr. Dhaliwal is hoping to soon use newly FDA-approved options such as Dextenza (Oc- ular Therapeutix), a hydrogel plug that elutes dexamethasone after cataract surgery, and in- tracameral, single injection Dexycu (dexameth- asone, EyePoint Pharmaceuticals), which is longer lasting than triamcinolone, she noted. "I have not had the opportunity to use either one, but the future is bright because we can take the patient compliance out of the equation," she said. continued from page 24 Every year at the ASCRS ASOA Annual Meeting, the YES Clinical Com- mittee holds a symposium of challenging cases and complications. Members of the committee present their mistakes, saves, and tips for many common issues that surgeons face. I've learned something useful each time I've been involved in the meeting and highly encourage young surgeons to attend. This is my final column as YES Connect co-editor. Samuel Lee, MD, and I are passing the baton to the excellent Julie Schall- horn, MD, and Claudia Perez-Straziota, MD, who I know will continue to make this column a useful and interesting resource for young surgeons. We are very thankful to the EyeWorld staff for all they do. David Crandall, MD, YES Connect co-editor

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