Eyeworld

EW FEATURE 59 ate on a white cataract, she likes to give a quarter of a gram per kilogram of mannitol (Osmitrol, Baxter Healthcare Corp., Deerfield, Ill.) 15- 20 minutes prior to the cut, which helps alleviate posterior and in- tralenticular pressure. "You don't want to do it way ahead of time because the patient will have to pee on the table, and you don't want to do it less than 15- 20 minutes ahead because it's not ef- fective," she explained. "Mannitol is an osmotic agent, and you have to be a little cautious in the setting of extreme or uncontrolled congestive heart failure or brittle diabetes. But other than that, it's a pretty benign thing to do to someone systemati- cally." In extreme cases, where the lens is so intumescent that it's difficult to pressurize the eye because the cham- ber has been shallowed by a swollen, almost abscessed lens, Dr. Masket will perform a small posterior vitrec- tomy. It softens the eye and allows him to deepen the chamber with viscoelastic. Dr. Ingraham and Abhay Vasavada, M.D., director, Iladevi Cataract & IOL Research Centre, Raghudeep Eye Clinic, Ahmedabad, India, stressed the importance of cre- ating a small capsulorhexis initially. "The larger the rhexis, the greater the chance for the rhexis to extend to the periphery," said Dr. Vasavada. "If you feel you can, do a smaller rhexis than you'd normally do. Then enlarge the rhexis later when you remove the cataract." The doctors also suggest using a more viscous viscoelastic, such as DuoVisc (sodium chondroitin sulfate, sodium hyaluronate, Alcon, Fort Worth, Texas), Healon GV, or Healon5. "If you don't do these things, and you don't anticipate these things, then [AFS] happens a lot," said Dr. Arbisser. "But if you do these things, it virtually never happens." Despite best efforts and precau- tions, AFS can occur in the hands of even the most skilled surgeon. At that point, it's crucial to remember not to panic and calmly prevent the tear from extending around the equator. "While we all like every case to follow our plan, we must accept that the vagaries of human tissue and human skills can allow the atypical to occur," said Dr. Masket. "As long as surgeons have pre-considered the plan they would follow under those given circumstances, they don't have to panic." In an AFS situation, Dr. Masket reminded physicians to take a deep breath and calm down. "The wonderful thing is one could always remove the instru- ments from the eye, repressurize the eye with a visco agent, reassess the anatomy, and then make a plan for how to progress," he said. "Fortu- nately, if you keep your senses, the opportunity exists to regroup your thoughts and go with plan B." Plan B must include finding and securing the ends of the tear and im- mediately stabilizing the pressure be- tween the anterior and posterior chamber. The eye has to remain static. "You need to add more vis- coelastic in a gentle fashion to not overfill or else you're creating pres- sure that allows the tear to cross the zonules around the equator to the back," said Dr. Arbisser. "Neither can you from now on throughout the case allow the chamber to shallow or it will tear across. So now, for the rest of the case, you must know where the limits of your tear are, keep it covered with visco, and keep your chamber stabilized." When it's time for phaco, Dr. Arbisser favors a vertical chop tech- nique over a divide-and-conquer. "I kind of lollipop the nucleus, divide it into pieces, and suck it up with just enough phaco to be able to assist aspiration," she explained. "I do a vertical chop on that so there's no pushing." Once the nucleus is out, Dr. Arbisser suggested stabilizing the chamber again and taking the time to do a dry cortex removal. "You have to be certain the hap- tics are where the two totally intact halves of the bag are," she said. "You can't allow it to be in a position where the haptic can pop out of the bag where the tears are and be in the sulcus." This type of complication may slow Dr. Arbisser down to a 45- minute case, which surgeons and staff need to be prepared for. "When I recognize there's an impending complication, I say the word 'timing,'" she said. "Everyone in the room knows we don't prep the person in the next room. We have a tough case bin that we keep extra stuff in. They have that at the ready if I say 'timing.' We're pre- pared for anything." Too complicated for phaco It doesn't happen often, but there can be white cataract cases too com- plicated for phacoemulsification. Sometimes it's not the cataract itself that's the problem; it's other factors in the eye, such as a compromised cornea and the absence of zonules. In those instances, Dr. Masket will do an intracap or a pars plana vitrec- tomy. Dr. Ingraham, on the other hand, has on occasion converted the procedure to an extracap or manual small incision surgery because of hy- permaturity. He favors the manual small incision over the extracap be- cause he has more control over the eye. Furthermore, manual small inci- sion surgery is the standard during international mission work in a country lacking reliable technology or even power, so it's helpful to keep those skills fresh. "You can phaco anything if you're stubborn enough," said Dr. Ingraham. "I think you challenge the zonules and increase your risk of burning your wound because you're having to put so much power into the eye. It happens much less frequently than it used to because the machines have gotten so much better. "People need to be willing to say, 'I'm getting in over my head,'" he continued. "I think quite often surgeons say, 'This was my plan, and I'm going to stick with that plan come hell or high water.' But as long as we get the cataract out and the patient does well, then [diverting from that] is OK." EW Editors' note: Dr. Arbisser has financial interests with Alcon. Drs. Ingraham, Masket, and Vasavada have no finan- cial interests related to their comments. Contact information Arbisser: larbisser@eyesurgeonspc.com Ingraham: hingraham@geisinger.edu Masket: Ann McLean (assistant to Dr. Masket), avcweb@aol.com Vasavada: icirc@abhayvasavada.com February 2011 September 2011 Challenging cataract cases E very Friday, the Washington Watch Weekly is sent by e-blast to all ASCRS•ASOA members with updates on legislative, regulatory, PAC, and grassroots news. The e-blast is used to keep members informed of breaking news in Washington, request grassroots in- volvement through the ASCRS Grassroots website, update mem- bership on new/changing regulations, and request political contributions from ASCRS domestic members for eyePAC. Last week's Washington Watch Weekly encouraged members to contact their legislators while they were on August recess. Although recess is over, you can contact your legislators through the ASCRS grassroots website. All members should consider contacting their legislators and asking for their support on the following legislative issues: • Permanent repeal and replacement of the Sustainable Growth Rate (SGR) formula. Physicians currently face yet another 29.5% reduction effective January 1, 2012, with additional cuts pending if Congress fails to act this year; • Repeal of the Independent Payment Advisory Board (IPAB), made up of 15 unelected, unaccountable members appointed by the President and required to make recommendations to Congress on how to lower costs to the Medicare program and Medicare physician payment policies, by supporting the House bill introduced by Congressman Philip Roe (R- TN), Medicare Decisions Accountability Act of 2011 (H.R. 452), and the Senate bill introduced by Senator John Cornyn (R-TX), "Health Care Bu- reaucrats Elimination Act" (S. 668); and • Support private contracting legislation, the "Medicare Patient Empower- ment Act" H.R. 1700/S. 1042 that allows patients the right to obtain medical services from the physician of his/her choice. For more detailed information on all of the ASCRS 2011 Legislative Priorities, go to: http://www.ascrs.org/Government-Relations/Advocacy.cfm To stay up to date on important issues affecting your practice and your patients, please continue to read the Washington Watch Weekly each week. To receive the Washington Watch Weekly, please contact ASCRS PAC/Grassroots Specialist, Gerrie Gray-Benedi at gbenedi@ascrs.org For more on ASCRS Government Relations (current legislative issues, eyePAC, regulatory issues,), go to: http://www.ascrs.org/Government-Relations Washington Watch Weekly An excellent ASCRS•ASOA member benefit

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