Eyeworld

EW FEATURE 62 Issue 2: What is the best timing for cataract removal in a case involving a ruptured globe? "When the globe is ruptured, this is an ocular emergency where the pri- mary aim is wound closure to restore the wound integrity," Dr. Chee said. "However, if the lens is severely dis- rupted due to penetrating injury and lens material spills into the vitreous, I would remove the lens at the time of globe repair since mixed lens mat- ter with vitreous is a risk factor for the development of endophthalmi- tis, especially in heavily contami- nated wounds." Whenever possible, she urged delaying lens surgery to a later date. In the presence of posterior seg- ment involvement, such as vitreous hemorrhage or retinal detachment, she recommended leaving the eye aphakic until the posterior segment issue has stabilized. "If the trauma is such that the crystalline lens needed removal in the absence of significant posterior segment involvement and the IOL could easily be placed in the bag or sulcus, I would do that at the time of the primary surgery," she said. Dr. Stegmann stressed that based on his experiences involving over 5,000 trauma cases, in instances of penetrating injury if the blood aqueous barrier is broken down, it is never wise to put in an intraocular lens as a first procedure, since this can lead to far greater complica- tions. "If it is a very simple laceration, if it's small and if the patient pres- ents early, you can do the intraocu- lar lens at the same time as the repair," he said. "However, if it is a more complicated case it is far better to do the cataract and then come back as a secondary procedure after the blood aqueous barrier has been restored by the use of steroids and non-steroidal eye drops." This can take up to 3-5 months. If the globe is ruptured due to blunt trauma, this becomes a team effort. "You're going to have to get the cataract out of the way so that the retina and vitreous doctors can see what they're doing," Dr. Stegmann said. In the interim, he stressed that there is no rush to get the lens in, especially in an adult. "You can go 6 months without af- fecting the ultimate visual out- come," he said. Issue 3: How do you feel about a pars plana approach for an anterior segment surgeon? In Dr. Arbisser's opinion, this is the safest and most appropriate way to remove vitreous. However, she stressed that this is only in the hands of those who have learned to make a pars plana incision. "If you've never done it, you don't want to read about it and then do it when you're in trouble in a compli- cated case," she said. In order to effectively learn to do this, she suggested apprenticing with a local retina surgeon. How- ever, she acknowledged that not all will be receptive. "You want to make sure that whoever you refer your complications to is not hostile to this point of view because that could be bad for you," Dr. Arbisser said. Some retina surgeons see this as strictly the purview of the retina fel- low. "But that's not true in the rest of the world in the training, and I think that it does the patient a sig- nificant disservice because when we do a pars plana approach, we're call- ing the vitreous home rather than calling it forward," she said. "We have a better view, we're more effi- cient, we're away from most of the viscoelastic, we're less likely to do collateral damage in the capsule and iris, and we remove less vitreous in order to get the vitreous home." Christopher M. Andreoli, M.D., vitreoretinal surgeon, Harvard Vanguard Medical Associates, and clinical instructor of ophthalmology, Harvard Medical School, Boston, sees things differently. "I feel that in some cases a traumatic cataract may be best approached with the retina surgeon employing techniques through the pars plana," he said. "I think that there's an advantage to pars plana approaches depending upon the particular situation; how- ever, there's additional benefit to having vitreoretinal expertise in- volved with many of these types of cases in the event of posterior com- plications and in light of a retina surgeon's more frequent experience with that approach." Overall, when Dr. Stegmann became interested in the field it had always been doom and gloom. How- ever, he no longer sees it that way. "If you handle these cases properly you can achieve miraculous results," he said. EW Editors' note: Dr. Arbisser has financial interests with Alcon. Dr. Chee has financial interests with Bausch & Lomb Surgical (Aliso Viejo, Calif.). Drs. Andreoli and Stegmann have no finan- cial interests related to their comments. Contact information Andreoli: christopher-andreoli@yahoo.com Arbisser: drlisa@arbisser.com Chee: chee.soon.phaik@snec.com.sg Stegmann: eyeclinic@ul.ac.za, 27-12-361-60-38 February 2011 Challenging cataract cases September 2011 © Eagle Laboratories 2011 Cannulae for LASIK 610-25 LASIK Flap Spatula/Irrigator (Hersh) 25GA x 1" Angled, 9mm bend to tip 611-25 LASIK Flap Spatula/Irrigator (Hersh) 25GA x 1" Angled, 4mm bend to tip Non-invasive spatula tip allows for safe lifting of the flap and curved angle to smooth the flap during alignment, open end for irrigation. Non-invasive flat spatula tip allows for safe lifting of the flap and curved angle to smooth the flap during alignment, open end for irrigation. 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Compressed spears are ideal for controlling and absorbing fluid in and around the orbital area during LASIK. 600-15 Pre-Expanded LASIK Spears Pre-expanded PVA eye spears offer a LINT-FREE absorption surface. Faster wicking than compressed spears. Pre-expanded spears are ideal for aligning and smoothing the corneal flap. 1-3 page cannula ad 1010 b.qxd 7/25/11 11:42 AM Page 1 Managing continued from page 61 EyeWorld factoid In about 90% of cases, people who have cataract surgery have better vision afterward Source: National Eye Institute, National Institutes of Health

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