Eyeworld

I CHALLENGING CATARACT CASES or the lens appears under pressure, Dr. Visco will adjust the laser parameters to perform the capsulotomy even faster, to help decrease the chance of an incomplete rhexis or a tear out. As Dr. Raviv concurred, "A slower [capsulotomy] will likely be incomplete, since as soon as the capsule is entered, liquified cortex exits, block- ing the femto, moving the capsule, and still leaving a risk of radialization." "The challenge with a white cataract is if you're using a femto laser, the energy for soft- ening the lens won't penetrate," Dr. Kang said. The bottom line is: Keep the laser in mind as a tool, but don't expect it to be your go-to for all dense white cataracts you treat. That said, it still could be helpful for astigmatism correction if needed, Dr. Kang said. Dr. Visco recommends having intraocular scissors on hand for whichever approach you use, be it femtosecond or manual. These can help you adjust the course for a capsulotomy that has gone wrong with either approach. Another pearl from Dr. Visco: Don't as- sume what kind of IOL or astigmatism correc- tion the patient wants just because they have a white cataract. Although many of these patients may not qualify for premium technology due to other diseases present, such as diabetes, she still has treated patients who have wanted a premi- um refractive result. "It's our due diligence to make sure the patients know all their options," she said. • Use a stop-and-chop technique to disassem- ble the nucleus, Dr. Kang said. A femtosecond laser can potentially help with capsulorhexis creation as it's quick, Dr. Visco said. However, surgeons should use what- ever is most comfortable for them, be it manual or with the femto laser, she added. "Femtosecond laser capsulotomy has helped with white cataracts, though it's not fool- proof," Dr. Raviv said. Another advantage with the laser is that you can obtain Scheimpflug or OCT imaging of the lens to see what is happening internally. If imaging shows that the chamber is shallow Relevant financial interests Al-Mohtaseb: None Gayton: None Kang: None Katsev: None Raviv: None Visco: None person in that country, the host whis- pered to Dr. Gayton, "Do you realize that if you mess up, you are going to cause an international incident?" The pearl: Know how to handle hyper- mature cataracts, especially if you are doing surgery in third-world countries. • A female patient had dense white cataracts for years in both eyes. Dr. Gayton performed simultaneous, bi- lateral surgery for the only time in his Better management of challenging cataracts gives patients incredible life improvement. Dr. Gayton shared three stories about treating hypermature cataracts and how it changed patients' lives. "These stories and millions more like them are why we do what we do," he said. • While launching phaco in Mongolia a few years back and doing surgery on a hypermature cataract in an important "These stories are why we do what we do" SEPTEMBER 2019 | EYEWORLD | 59 Hypermature cataract Source: Johnny Gayton, MD career. "We positioned her daughter so that the first thing she saw when opening her eyes was her daughter. There wasn't a dry eye in the house," he said. • A patient with only weeks to live had bilateral hypermature cataracts. In the recovery area, the patient looked up, saw his daughter, and said, "That is the prettiest thing I've ever seen."

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