NOV 2013

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

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a 10 cc syringe and a 27-gauge Chang or Akahoshi cannula. Careful injection of balanced salt solution will allow it to circulate around the lens, underneath the OVD shells, and out of the eye through the phaco incision without disturbing the shells. Hydrodissection may occasionally disrupt the OVD shell, in which case the viscoadaptive is always the layer lost. If this occurs, simply rebuild the viscoadaptive layer and the balanced salt solution layer beneath it before proceeding. 6. Lower flow rates during phacoemulsification tend to preserve the OVD shells better. Dr. Arshinoff routinely uses a flow rate of 32 cc/min, a bottle height of 95 cm above the patient's eye, and a vacuum limit of 330 mm Hg. 7. With patience, the TSST shells will remain undisturbed. The phaco and I/A tips should be kept deep to the plane of the capsulorhexis to contain flow within the capsular bag, minimizing the disturbance of the soft shells and the turbulence to which the iris and the endothelium are exposed. 8. Once the I/A has been completed, the anterior chamber is partially filled, in the area of the incision, with a viscoadaptive, to blockade the incision. Balanced salt solution is subsequently injected through the viscoadaptive to fill the capsular bag. The balanced salt solution is retained in the capsular bag by the viscoadaptive blockade of the incision. The IOL is then inserted into the capsular bag with an injector. Once the leading IOL haptic has been inserted under the distal capsulorhexis edge, and the IOL deposited entirely within the anterior chamber, the I/A is reinserted, turned on, and used to nudge the trailing haptic, causing it to fall into the balanced salt solution filled capsular bag and open. The OVD can then be removed using I/A in a few seconds by "rock 'n' roll" without having to go behind the IOL. As more experience is gained, viscoadaptive blockade can be limited to the incision and the adjacent capsulorhexis, with the remainder of the AC and capsular bag filled with balanced salt solution (Figure 1E, F). The TSST is meant to be a paradigm developed using physical principles for the rational use of multiple OVDs in concert to optimize cataract surgery. Consequently, it can be adapted depending on the particular needs of a surgery. For simple cataracts, the TSST can be modified into the ultimate soft shell technique (USST) omitting the dispersive OVD. Alternatively, if a patient has severe IFIS, the soft shell bridge (SSB) approach can be performed by simply injecting enough dispersive OVD in the first OVD step to cover not only the endothelium, but also the iris. Figure 2 illustrates the relationship between the various soft shell techniques that have been described. As OVD development continues it is likely that further modifications will become possible. The underlying framework described here, however, will continue to be valid, and hence can be used to guide the use of OVDs for anterior segment surgery. EW Reference Arshinoff SA, Norman R. Tri-Soft Shell T echnique. J Cataract Refract Surg 2013; 39:1196-1203. Editors' note: Dr. Arshinoff is in private practice at York Finch Eye Associates, Humber River Hospital, Toronto. He is affiliated with the University of Toronto, McMaster University (Hamilton, Ontario), and Ben Gurion University of the Negev (Beer-Sheva, Israel). He has financial interests with Alcon, AMO, Anteis (Geneva), Artic Dx (Toronto), and Bausch + Lomb (Rochester, N.Y.). Mr. Norman is completing his fourth year of medical school at the University of Toronto. He has no financial interests related to the article. Dell* Toric Axis Markers Precise Alignment For Correct Toric Axis Placement, From Upright Through The Supine Position. ting Bezel With Rota ns Marker d Toric Le Position Dell Fixe In Supine 8-12119: n Patient Is Used Whe ker Mar ens d When ric L e el To ezel Us ition wiv Pos ell S ing B : D h Rotat Upright 120 Wit Is In 8-12 nt Patie 8-12119: R o t a t i n g I n n e r Bezel Automatically Orients Marks For The Placement Of A Toric IOL In The Correct Meridian. While The Patient Is Upright, An Orientation Mark Is Placed Vertically On The Conjunctiva. In Surgery The Rotating Inner Bezel Is Set To The Desired Meridian. While The Instrument Is Positioned So That The Vertical Conjunctival Mark Is Aligned With The 90 Degree Position On The Outer Bezel Of The Marker. The Marking Blades On The Undersurface Of The Instrument Will Automatically Place A Mark In The Correct Meridian When The Cornea Is Indented. 8-12120: Weighted So That Correct Horizontal Orientation Is Assured. Rotating Inner Bezel Automatically Orients Blades For Corneal Marks For The Placement Of A Toric IOL In The Correct Meridian. Designed For Use With The Patient Upright Immediately Prior To Surgery, The Inner Bezel Is Rotated To The Desired Meridian, And The Cornea Is In de nt e d. T he M a rk i ng B l a de s O n Th e U n de r s u r fa ce Of Th e Instrument Will Automatically Place Marks In The Correct Meridian. www.RheinMedical.com Contact information Arshinoff: ifix2is@sympatico.ca Norman: richard.norman@mail.utoronto.ca 3360 Scherer Drive, Suite B. St.Petersburg, Florida s 4EL s &AX %MAIL )NFO 2HEIN-EDICALCOM s 7EBSITE WWW2HEIN-EDICALCOM $EVELOPED )N #OORDINATION 7ITH 3TEVEN * $ELL -$ Moses, Michelangelo 1269 Rev.D BABC

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