Eyeworld

AUGUST 2020| EYEWORLD | 33 C Contact Braga-Mele: rbragamele@rogers.com Titiyal: titiyal@gmail.com Vasavada: icirc@abhayvasavada.com "A gentle bimanual irrigation/aspiration of anterior lens cortex is required to decompress the intumescent cortex. Subsequently, the cap- sulorhexis may be completed using a microfor- ceps," he explained. Dr. Braga-Mele emphasized the importance of maintaining positive pressure in the eye if the capsulorhexis running occurs. "Your second instrument could be your viscoelastic in your non-dominant hand to keep refilling and maintaining the anterior chamber effectively," she said. In an Argentinian flag sign case, Dr. Vasavada said if you see the limbs of the tear floating, there is likely no vitreous. If the sides of the tear are not moving, Dr. Vasavada said vitreous could be sitting on them. In either case, the capsule should be stained to assess the extent of the tear. Triamcinolone can be used to identify vitreous. If there's no vitreous, Dr. Vasavada said the trick is a slow-motion tech- nique, with a low bottle height and low aspira- tion flow rate. "The key is to produce multiple small frag- ments. If you try to bring a big fragment out, that could further extend and stretch the tear," he said. If there is vitreous, Dr. Vasavada recom- mended a pars plana vitrectomy to prevent extension of the tear and minimize vitreoretinal traction. In terms of a lens choice, Dr. Braga-Mele said in the aforementioned case, she was able to implant a lens in the capsular bag because the posterior capsule remained intact. If the pos- terior capsule wasn't intact, she said you'd want to put a three-piece lens in the sulcus with the haptics 90 degrees away from the Argentinian flag sign to ensure zonular stability. Gluing or sewing the lens might be required if the bag is gone, or if the patient is 85 years or older, you could consider an anterior chamber IOL. As a final pearl, Dr. Braga-Mele said if the case is a short eye with a white cataract, you could consider acetazolamide preoperatively to decrease IOP from the start. such as the femtosecond laser or Zepto (Cen- tricity Vision, formerly Mynosys). Stain with trypan blue, pulling the capsulotomy toward the center, being wary of tags. Dr. Titiyal said he prefers to use the femtosecond laser in all white cataract cases that don't otherwise have a con- traindication (poor pupil dilation, for example). "Femtosecond laser helps in the creation of a single-step, circular, adequately sized capsu- lotomy and eliminates the difficulty associated with capsulorhexis in white cataracts. We have observed an abrupt release of white milky fluid during femtosecond laser delivery to be the most important factor affecting the creation of a free-floating capsulotomy," he said. Dr. Titiyal also emphasized the importance of staining the capsule to identify residual adhe- sions of the capsulotomy. "We could create continuous capsulotomies in 94.1% of cases with fluid and 100% of cases with no fluid with our technique of femto- second laser-assisted cataract surgery despite the high incidence of micro-adhesions in our study," he said. 2 Dr. Vasavada said he likes using the femto- second laser, especially for intumescent cata- racts. If he thinks it's necessary from a clinical standpoint, he'll pay for it on behalf of patients who can't otherwise afford it. In manual cases, Dr. Titiyal uses anterior segment or intraoperative OCT to characterize the morphological features of the white cataract and guide his capsulorhexis. He'll fill the AC with cohesive OVD before starting the capsu- lorhexis and use a dispersive over the cohesive. "The cohesive OVD facilitates easy ma- nipulation of the anterior capsular flap and the dispersive OVD tamponades the flap and does not allow the cohesive OVD to escape," he said. Dr. Titiyal added that he doesn't aspirate fluid in all white cataracts, preferring controlled aspiration of subcapsular fluid after initial small capsulorhexis in cases of white cataract with raised ILP/liquefied cortex. If an Argentinian flag sign does occur, Dr. Titiyal immediately injects a dispersive OVD over the capsular flap via a paracentesis to tamponade and prevent further extension. References 1. Titiyal JS, et al. Elucidating intraoperative dynamics and safety in posterior polar cataract with iOCT guided phacoemulsi- fication. J Cataract Refract Surg. 2020. Online ahead of print. 2. Titiyal JS, et al. Comparative evaluation of femtosecond laser-assisted cataract surgery and conventional phacoemulsi- fication in white cataract. Clin Ophthalmol. 2016;10:1357– 1364. Relevant disclosures Braga-Mele: None Titiyal: None Vasavada: Alcon Intumescent white cataract with shallow anterior chamber, bulging anterior capsule, and subcapsular fluid clefts Source: Jeewan Singh Titiyal, MD

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