EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/220233
34 EW CATARACT November 2013 Pioneering a way to better manage dense cataracts by Vanessa Caceres EyeWorld Contributing Writer Father/son surgical team share their approach A father/son surgical team has a battle plan in place to tackle dense cataracts. Richard J. Mackool, MD, Mackool Eye Institute, Astoria, N.Y., and his son R.J. Mackool, MD, Mackool Eye Institute, and attending surgeon, New York Eye and Ear Infirmary and New York University Medical Center, New York, emphasize the value of both technique and technology to better manage dense cataracts. "Technology can make the procedure easier, but technique is your game plan," said Dr. Richard J. Mackool. Examining technique With a dense cataract, the Mackools advise first attempting to assess the zonular status and whether pseu- doexfoliation is present. This can help you decide the approach you want to take. "If there's a concern about the zonule and/or compromising them during surgery, we'll put in Mackool Cataract Support System or MST capsule retractors [MicroSurgical Technology, Redmond, Wash.] every 45-90 degrees to stabilize the bag," said Dr. R.J. Mackool. They will then divide the nucleus into two hemi-nuclei, chop each hemi-nucleus in half with the Mackool Chopper, and use a more powerful tip than they might otherwise. Dr. Richard J. Mackool recommends sculpting deeply. "When sculpting deeply, be certain that you can always see the port of the tip. You need to see what you're doing and use the microscope to magnify your view appropriately," he explained. The Mackools will sculpt deep enough to see a red reflex and/or a sheen to indicate that nuclear thinning is sufficient to permit the nucleus to be divided. "You also have to get peripheral enough when you make the groove in the nucleus so it chops easier," said Dr. R.J. Mackool. He recommended creating a nice, long trough, after which you would only need to apply a little force in the center of the trough to create two hemi-nuclei. "Once that's done, you rotate the nucleus 90 degrees and then perform the first chop." Dr. R.J. Mackool said it takes some practice to sculpt deeply and it's often a surgeon's tendency to not go deep or peripheral enough. However, going deep and peripheral is necessary in order to reduce stress on the zonule when attempting to divide the lens. Capsule retractors are an integral part of the procedure. "They're essentially a scaffold that takes the stress off the zonule during division of the nucleus. My advice is to use them early and often," said Dr. Richard J. Mackool. Utilizing technology Centurion Vision System Source: Alcon Technology is another important part of the Mackools' game plan for dense cataracts. They said their surgical performance on dense cataracts has become easier with the use of the Centurion Vision System (Alcon, Fort Worth, Texas), which launched globally in September. The Centurion system continually adapts to changes in the eye, with more tightly controlled fluidics that provides greater anterior chamber stability, according to information from Alcon. For example, if there is a clogged tip, the machine will recognize an obstruction is present and shift from the torsional to a preprogrammed amount of traditional linear ultrasound to clear it and thus expedite the removal process, said Dr. Richard J. Mackool. As consultants for Alcon, the Mackools were among the 40 surgeons around the world who were able to use the technology before it was commercially released. Dr. Richard J. Mackool finds the system permits a wide range of vacuum pressure to be used. "The Centurion eliminates the need for a high infusion bottle," he said. "With the pressurized infusion, one can turn the dial to the desired IOP setting, and then proceed to use a safe vacuum pressure to hold the nucleus on the tip," he said. Although the Mackools used a large 1.1 straight, flared 45-degree tip in the past, they now use Alcon's Intrepid Balanced Tip, which is part of the Centurion system. The tip is more powerful than today's typical torsional standard tip, said Dr. Richard J. Mackool. "In dense nuclei, you want to get maximum power. You don't want to phaco ineffectively. A higher-power phaco tip permits the nucleus to be removed more rapidly with less total fluid flow through the eye," he said. The Mackools also make use of femtosecond laser technology suited for cataract surgery in dense nuclei. For instance, if a cataract is so dense that it is white, they prefer the use of femtosecond laser technology to perform the capsulotomy, said Dr. R.J. Mackool. Anticipating complications The Mackools said they have not had to switch to extracapsular cataract extraction with the use of their current technique. "The only time we'd convert is in an eye with corneal opacification that prohibited an adequate view of the phaco procedure," said Dr. Richard J. Mackool. So far in his career, Dr. R.J. Mackool has not yet encountered phaco burns. "My father taught me well. You always want to make sure you have flow. As long as you have flow, you won't get wound burn with today's equipment," he said. That's why phaco technology that helps eliminate tip obstruction is particularly useful, he said. Still— "There's no substitute for knowing when things are moving and when they are not," he added. The Mackools have videos of their surgical technique available at www.mackoolonline.com. EW Editors' note: The Mackools have financial interests with Alcon. Contact information R.J. Mackool: 718-728-3400, richardmackool@aol.com Richard J. Mackool: 718-728-3400, phacodr@aol.com