JAN 2014

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

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February 2011 January 2014 Phaco and vitrectomy what's vitreous, Dr. Snyder added. Both surgeons also use triamcinolone at the end of a case after a vitrectomy to ensure all the OVD and vitreous is managed. "If the OVD is already there, Triesence is of little value to you because the OVD prevents the Triesence from getting to stain the vitreous. It won't stain the OVD, but it's blocked by the OVD from clinging to the hyaluronic structure of the vitreous. So the first thing you need to do if you run into trouble is decide if you need to do a vitrectomy," Dr. Arbisser said. Pearls for use When using Triesence, Dr. Arbisser recommends diluting it 1:10 with balanced salt solution. "That way, it can last throughout the procedure, be used more than once, and it doesn't create a big, ropey strand of white stuff that blocks your view that you then have to dilute inside the eye," she said. Vitrectomy should be biaxial "so that the irrigation goes through the paracentesis and the bare vitrector needle either goes through a new paracentesis anteriorly or through a pars plana incision," she advised. When a complication is recognized and the chamber stabilized with OVD, the vitrectomy precedes the use of the Triesence. If you're unsure if vitrectomy is needed the OVD cannula can be placed through the posterior capsule rent; if the OVD falls into the vitreous rather than defining Berger's space the anterior hyaloid is no longer intact. Once an endpoint of removing all prolapsed vitreous has likely been reached this can be confirmed with Triesence. Keeping the vitrector in position, withdraw the irrigation cannula, which is in the paracentesis, exchange it for the Triesence cannula, instill Triesence through the paracentesis and then replace the irrigation cannula to clear the Triesence cloud. This will clearly confirm that the endpoint of removing all prolapsed vitreous has been reached or if there's a strand up by the incision you might have missed, Dr. Arbisser said. Dr. Snyder cautions that patients will need to be followed for any pressure rises within the first month or so postop until the triamcinolone is gone. "Be alert for a steroid response," he said. "Also, the granules themselves can clog the meshwork." He also cautioned that when some triamcinolone is purposely left in the eye, "when it's circulating around it will layer out in the lower anterior chamber angle and it may look like endophthalmitis because it has a similar appearance to hypopyon but it will be a different color." To differentiate, residual triamcinolone will be more of a chalky white, while the inflammatory white blood cell hypopyon associated with endophthalmitis is more of a cream color, he said. Dr. Snyder also suggested surgeons go no smaller than a 27 g needle as the crystals get hung up in a 30 g. Dr. Arbisser offered this additional pearl: Once the triamcinolone has been mixed in the syringe, "if you want to use it later after it's been sitting on the stand, draw back a little bubble and roll it around to resuspend the solution and then remove the bubble before using it again. Otherwise, you'll end up with just the diluent and the suspension stays in the syringe." Other scenarios Anytime a surgeon is planning a complicated cataract case, Dr. Arbisser recommends having triamcinolone on hand and ready to use. She'll swirl it around in the anterior chamber after using Miochol E (acetylcholine chloride intraocular solution, Novartis, Basel, Switzerland) to ensure no strands are left as the last maneuver in every complicated case, and then plans to leave some in the eye for both diagnostic and therapeutic reasons. EW FEATURE 43 Dr. Snyder also plans to use triamcinolone in uveitic cases, and dilutes it 1:10 with balanced salt solution. The anterior chamber is filled with the dilute mix at the end of the case. He'll often inject the excess into the subconjunctival space "since it's already there. It will never hurt to have a subconjunctival steroid depot there a bit longer especially in these kinds of inflammatory cases." Dr. Arbisser uses Triesence intramerally for uveitis patients and also cases involving iris manipulation (i.e., Malyugin ring, synechiolysis), pediatric cases, and any patient with diabetic macular edema. EW Reference 1. Burk SE, Da Mata AP, Snyder ME, Schneider S, Osher RH, Cionni RJ. Visualizing vitreous using Kenalog suspension. J Cataract Refract Surg. 2003 Apr;29(4):645-51. Editors' note: Dr. Arbisser has financial interests with Abbott Medical Optics (Santa Ana, Calif.), Bausch + Lomb (Rochester, N.Y.), and Alcon. Dr. Snyder has financial interests with Alcon. Contact information Arbisser: 309-793-2020, drlisa@arbisser.com Snyder: Msnyder@cincinnatieye.com Poll size: 335 EyeWorld Monthly Pulse EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthalmologist. Each month we send a four-question online survey covering different topics so our readers can see how they compare to our survey. If you would like to join the hundreds of physicians who take a minute a month to share their views, please send us an email and we will add your name. Email carly@eyeworld.org and put EW Pulse in the subject line—that's all it takes. Copyright EyeWorld 2014

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