Eyeworld

I CHALLENGING CATARACT CASES N FOCUS Dr. Gayton added that the capsular opening is key. "Take as much time as you need to get a good result for the patient," he said. Dense white cataracts Dense white cataracts are unpredictable, and surgeons often do not know what is causing them to be white. "When you approach a white cataract, be ready for anything," said Paul Kang, MD. "If you can get [details] from the patient history or by looking at the cataract, it can help. Oftentimes, it's not possible." Denise Visco, MD, likens a dense white cat- aract to driving in a blizzard. "Eventually, as you begin working, everything gets kind of white, and you don't have good contrast between the capsule and lens," she said. "White cataracts can either behave like any other cataract or they can have increased intraocular pressure with a high risk of anterior capsule tear out—the dreaded Argentinian flag sign," said Tal Raviv, MD. To help better manage these challenging cataracts and avoid additional surgical surprises, the surgeons shared a few suggestions: • Create a good incision at the beginning that will not leak during the case. "It all starts with a good incision," Dr. Visco said. "If you're burping out viscoelastic or have poor cham- ber stability, it'll make things more difficult." • Make sure the patient is dilated widely. Dr. continued from page 56 About the doctors Zaina Al-Mohtaseb, MD Associate professor of ophthalmology Baylor College of Medicine Houston Johnny Gayton, MD Eyesight Associates Warner Robins, Georgia Paul Kang, MD Assistant clinical professor Department of Ophthalmology Georgetown University Washington, D.C. Douglas Katsev, MD Sansum Clinic Ophthalmology Santa Barbara, California Tal Raviv, MD Eye Center of New York New York Denise Visco, MD Medical director Eyes of York York, Pennsylvania Cracking the dense nucleus with the fibers from the posterior plate Source: Zaina Al-Mohtaseb, MD The dreaded Argentinian flag sign of capsular radialization Source: Tal Raviv, MD Kang will use epi-Shugarcaine to help with the view. • Stain the capsule with trypan blue. "If there's not a good red reflex, it's difficult if not im- possible to see without some stain," Dr. Kang said. • Be mindful of your choices for an ophthal- mic viscosurgical device (OVD). Dr. Kang uses a combination of Viscoat (sodium chondroitin sulfate/sodium hyaluronate, Al- con) on the endothelium along with Healon5 (sodium hyaluronate, Johnson & Johnson Vision) or a similar OVD. "In this case, I'm using Viscoat because I'm anticipating the cataract may be a little denser, and I want to protect the endothelium. I'm also anticipating the lens might be under pressure, which is why I'll want to use a viscoelastic with a high- er molecular weight so it won't readily escape the anterior chamber," he said. • Keep the chamber pressurized, and release pressure if needed in a controlled manner. During that time, you often can find out if the cataract is rock hard or soft, Dr. Kang said. • If an advanced white cataract has capsular plaque, try to plan the capsulotomy around the plaques so they will not tear, Dr. Raviv recommended. "If they are extensive, curved microscissors will be necessary to complete the rhexis," he said. 58 | EYEWORLD | SEPTEMBER 2019

• Blank Page
• Blank Page (1)