AUG 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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50 EW RESIDENTS August 2013 Cataract M&M rounds Tackling wound construction issues H ere is a case that presents a relatively common complication. We are fortunate to have three experienced cataract teachers tell us how they would guide their residents through the rest of the case. We have also provided a link to the video showing how we moved forward with this case at the University of Iowa. A 75-year-old man presented with gradual decline in vision, and we diagnosed him with a functionally significant cataract. He had few systemic medical issues, and we performed his surgery under topical anesthesia with a third-year resident in our program.IFigure 1 shows the keratome incision, which drifted long and started a bit anterior. This anterior and long incision made the rhexis difficult with striae while manipulating the forceps and other instruments.IMore difficult was the edema that began to develop in the long incision as the case progressed.IBy the time we performed aspiration of the subincisional cortical materialIabout half of the cornea was edematous andItheIdetails of the anterior chamber were difficult to see (Figure 2). We asked our expert teachers: How would you help to prevent this problem? After you detect a long incision, what do you do differently to help the case move safely along? How would you remove the residual cortical material in this situation? Thomas Oetting, MD, Cataract M&M rounds editor Watch this video on your smartphone or iPad using your QR code reader. (Scanner available for free at your app store.) www.facebook.com/video/ video.php?v=131725176140 Grace Sun, MD Director, ophthalmology residency program Assistant professor of ophthalmology Weill Cornell Medical College New York This case illustrates that how one starts the case can drastically affect the course of the surgery. Every step of surgery affects the subsequent step. A long, anterior main wound makes the rhexis challenging as one may distort the cornea while directing the Utrata forceps through a long, tight space. Further along, maneuvering the phaco handpiece through that wound creates a situation where the view is now significantly compromised by cornea edema. This can only prolong the case, as the level of difficulty begins to rise. And unfortunately, as you are in the eye longer, that corneal edema will worsen. As an instructor, as soon as you detect a long, anterior incision, you are already thinking steps ahead, as you know what may ensue. Depending on the complexity of the case, the level of experience of the resident surgeon, and your own level of comfort, one option is to create another main wound from the very beginning. However, I think many of us would use the original wound and see how the case progresses. Here, the surgeon has successfully removed the nucleus and has residual cortex remaining, located mostly subincisionally. At this point with visualization compromised by corneal edema, the subincisional cortex removal will have to be performed nearly "blind." Here is where experience and a strong understanding of the ocular anatomy and space may get you through this case. Without this, the risk for a capsular tear and subsequent need for anterior vitrectomy may be high. Here is how I would proceed if the resident is not equipped to proceed: 1. Attempt a sweep with the onepiece silicone I/A tip to remove the subincisional cortex. However, I think with a long, anterior wound, this will prove to be difficult without further wound distortion and edema. If that doesn't work … 2 Bimanual I/A: Create an additional paracentesis to attempt to remove the subincisional cortex via bimanual I/A. I've found that by creating these new wound(s), one may see that the eye will be slightly rotated differently, perhaps literally giving you a "window" of opportunity by allowing you a view through a less cloudy part of the cornea. And if that doesn't work … 3. Leave that subincisional cortex behind. Once the IOL is placed in the bag, gentle rotation of the IOL may often break the cortex loose. If not, I've always been cautioned that the enemy of good is perfect. There is a possibility that the residual cortex will not cause a problem with inflammation. If it does, we always consent our patients with the understanding that there may be a need for a second surgery. This can be done safely when the edema clears. Paul Pruett, MD Assistant professor, Emory University School of Medicine Residency program director Chief of service, Grady Health System Atlanta This is not an uncommon issue with early wound construction. I usually see this after a resident has performed a case where the wound was placed too posteriorly and resulted in hydration of the conjunctiva and Tenon's. I counsel the resident to avoid overcorrection of the previous mistake. Once this issue has occurred, the two problems identified in the case are quite common. Not only does performing the capsulorhexis become more difficult secondary to striae, but the capsulorhexis is also at higher risk of being too central in the subincisional area, making future cortical removal more challenging. To ensure an adequate capsulorhexis, I make sure the resident does not regrab the capsule underneath the wound. I instruct the resident to regrab just before the wound and not to let go until the capsulorhexis is past the incision. This prevents exacerbating any striae caused by an anterior wound. If the anterior portion of the wound precludes getting the capsulorhexis far enough into the periphery, then I will have the resident place the capsule on top of the lens and perform that part of the capsulorhexis using a cystotome through the paracentesis. Once the cornea has become hydrated, subincisional cortical removal is more challenging. If I had access to a bimanual irrigation/aspiration unit, this would be less of an issue. I utilize three different techniques to remove the cortex in this situation. If only minimal material is present, I will go ahead and insert the IOL into the bag and use the optic as a squeegee to loosen up the material. Then I can use the automated irrigation/aspiration unit to remove the material with the optic holding back the posterior capsule. If there is more material present, then I will create another paracentesis 180 degrees away from the wound and use a Simcoe cannula to manually aspirate the cortical material. This gives you the ability to rotate the eye and peek around the hydrated cornea. Lastly, I have filled the eye with viscoelastic and then used a 27-gauge straight hydrodissection cannula on a 3 mL syringe through the paracentesis to aspirate the subincisional cortex. The overarching theme is to minimize the use of the main incision so that corneal striae and corneal hydration do not combine into a visualization nightmare. Cynthia S. Chiu, MD Associate professor of clinical ophthalmology Director of comprehensive ophthalmology & optometry University of California, San Francisco

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