Eyeworld

MAY 2020 | EYEWORLD | 47 C Contact Koch: dkoch@bcm.edu Oetting: thomas-oetting@uiowa.edu ful when zonules are weak and there is concern that they may not hold up to nuclear fracture. "The idea is you're stabilizing the bag while you're doing nucleus removal," Dr. Oetting said. Typically, he likes to place these retractors before nuclear fracture. Once the bag is empty, he places a capsule tension ring and assesses whether he needs another device, such as a sutured capsular tension segment. Whenever Dr. Koch thinks the capsule is so weak that the lens will subluxate posteriorly, he relies on either Mackool hooks (FCI Oph- thalmics) or MicroSurgical Technology (MST) capsular hooks. With the MST hooks, he prefers the newer model that has a smaller opening that prevents it from getting entangled with the capsular tension ring. He also finds the Mackool hooks are easy to use. "They're placed as early as I need to assure good stability," he said. "The other 'device' that I use when I'm removing the nucleus is a lot of dispersive OVD, Healon EndoCoat [3% sodium hyaluronate, Johnson & Johnson Vision]. Injecting this into the bag provides a great cushion and prevents the bag from collapsing into the phaco tip." If needed, he may also insert a capsule tension ring for additional support during phacoemulsification. In these instances, a scleral-fixated Ahmed seg- ment (or two) is almost always used to assume long-term capsular stability. Capsule tension rings can make cortex removal more challenging, so Dr. Koch recom- mends viscodissecting away from the capsule before trying to aspirate it in order to minimize traction on the capsule. rings in cases where there is a lot of iris fibrosis because he's concerned it could lead to asym- metrical tears. He'll instead rely on iris hooks so he can titrate the amount that he opens. Dr. Koch said he'll also use iris hooks when he wants to better visualize one section of the eye. If the iris is floppy due to IFIS, however, he injects 1:5,000 epinephrine at the beginning of the case. This gives him enough stability and adequate pupil size to complete the case, some- times in conjunction with reinjecting dispersive OVD. Dr. Oetting uses intracameral epinephrine on every patient. "The truth of the matter with IFIS is patients aren't sure if they are on an alpha blocker," he said, adding you have to assume they're taking tamsulosin. Because of his "paranoia" about this, Dr. Oetting also avoids mechanically stretching the pupil because it can make IFIS worse. Dr. Koch finds that mechanical stretching tends to create asymmetric tears and, likewise, he has stopped doing this. For patients with small pupils, Dr. Oetting tends to use the Malyugin ring, which doesn't require any additional incisions that can affect the fluid dynamics of the chamber. He reserves iris hooks for cases with narrow angles with posterior synechiae. "In that situation, I'll simul- taneously lyse the synechiae and place the iris hooks," Dr. Oetting said. Stabilizing possibilities All hooks are not the same. For stabilizing the bag, Dr. Oetting finds capsular tension hooks, sometimes known as capsule retractors, are use- Relevant disclosures Koch: Alcon, Johnson & Johnson Vision Oetting: None A capsular tension ring is inserted with three clock hours of traumatic zonular loss. Because the remaining zonules were intact, the ring provided sufficient support for the capsule and IOL. In this case of nasal traumatic zonular loss, three Mackool hooks were inserted to support the lens during phacoemulsification. After all lens material was removed, a CTR was inserted, and an Ahmed segment was sutured to the sclera to provide good long-term capsular support. Source (all): Douglas Koch, MD

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