Eyeworld

EW CATARACT 82 October 2011 by Michelle Dalton EyeWorld Contributing Editor Causes of retained fibers vary Vigilance during the final phases of phaco can help prevent the annoyance A s careful as cataract sur- geons might be, on occa- sion, a fiber or cortex can be left behind. What causes the fiber to be in- troduced in the eye is of more con- cern than what happens once it is there—unless the fiber causes some type of inflammatory response, usu- ally the best treatment is no treat- ment, surgeons say. Although not terribly com- mon—during residency Eva C. Kim, M.D., Kaiser Permanente, Santa Clara, Calif., said she saw fibers in one of every 100 patients or so— "even one I thought was too many." When Dr. Kim first joined Kaiser, every cataract surgery was set up identically, which involved a sterile drape and a halo around the patient's head. The techs placed rolled-up blue towels that were part of the phaco kit in the wells to soak up some of the fluid, she said. Hav- ing never used those towels as a resi- dent or fellow, she began operating without them and requested the techs keep the towels away from her instruments as well. "Once that started, I noticed the amount of fibers decreasing. Not everyone in the group used the tow- els, and they'd still get fibers, but that's what I had it narrowed down to as the main cause," Dr. Kim said. Fibers can be introduced into the eye "from the drape or anything sur- geons use," said Divya Srikumaran, M.D., assistant professor of ophthal- mology, Wilmer Eye Institute, Johns Hopkins University, Baltimore. She said some surgeons use clear gauze rather than an instrument wipe, which may inadvertently leave be- hind a fiber or two. She's even had some fibers on the IOL itself. "I don't think they came in the box with the IOL; I think the process of loading the IOL may have intro- duced them," she said. Although she's never used the towels Dr. Kim has, "we've seen them so we know there have to be other causes." More annoyance than problematic Usually surgeons will be able to see any introduced fibers during the sur- gery itself. "I'm really sensitive to them, so when I'm vacuuming up the vis- coelastic out of the eye, I really pay attention and look for the fibers. I hate when they're in the eye during post-op day 1," Dr. Kim said. "It's troublesome to look at." Dr. Srikumaran said in her hands, she's only had one patient with retained fibers on post-op day 1 "and that patient ended up doing just fine." Dr. Kim said she can count on one hand the number of patients with retained fibers she's personally seen, "and I've never removed one, never needed to take anyone back to the OR. My personal threshold would be if the patient was having some kind of inflammatory re- sponse." If the patient develops post-op iritis, Dr. Kim said she'd blame a fiber if one was there but said other causes such as diabetes could be the culprit as well. For the most part, Dr. Srikumaran notices fibers perioperatively and re- moves them with viscoelastic. "It's happened when I've switched tips between the phaco handpiece and the I/A handpiece. Something gets caught on the tip and gets introduced," she said. "If that happens, I fill the eye with visco and take out the fiber with the utrata forceps." She's never encountered a fiber that's directly in the center of the vi- sual axis, but Dr. Srikumaran said "you could do a YAG capsulotomy and get rid of it if necessary." Dr. Kim said when she saw her first retained fiber, "my stomach fell." But since then, she's yet to have a patient where the fiber affects vision. "I've even had some patients where the fiber is really annoyingly in the middle of the pupil, but noth- ing happens with their vision," she said. "Then I'll see the patients a couple of years later and it's gone. It must have fallen—I don't look for it with gonioscopy." When it does happen, Dr. Kim alerts the patients, but stresses the fiber is not going to affect vision. Being vigilant during the irriga- tion step is key, she added. "Once you do notice it, it isn't as easy to remove as cortex might be," she said. She goes in with a can- nula to remove the fiber manually. Dr. Srikumaran seeps around the eye with her probe to make sure all the visco is removed (and any unin- tentional fibers as well). "I think you run into a higher chance of retaining fragments—not just fibers but nuclear tips as well— when you use a dispersive viscoelas- tic," she said. For newer surgeons, she said the key is not to panic. "Everyone is going to have a fiber at some point," she said. EW Editors' note: Drs. Kim and Srikumaran have no financial interests related to their comments. Contact information Kim: 408-851-4012, eva.c.kim@kp.org Shrikumaran: dsrikum1@jhmi.edu cal point in the case and being able to accurately predict the odds of that particular resident being able to han- dle the clinical situation at hand. The main obstacles to teaching ECCE include the incidence of ap- propriately brunescent cataracts that are ideal for this technique. Limited OR time and the desire to do more cases also diminish the incentive for the residents to book an ECCE. Ad- ditionally, for many volunteer fac- ulty members who rarely perform ECCE in private practice, it is not uncommon for them to express re- luctance in attending these cases, perpetuating the perception that this is an obsolete technique. Another teaching strategy we advocate is the backward step-wise approach to surgery, i.e., allowing the junior residents to participate in parts of a senior resident's case, start- ing with viscoelastic removal, insert- ing the lens, performing I&A, etc. We enjoy having the senior resi- dents supervise their juniors and watching them realize the patience and time it takes to sit at the assis- tant scope. EW Contact information Braga-Mele: rbragamele@rogers.com Dodick: jackdodick@aol.com Gattey: gatteyd@ohsu.edu Park: drlisapark@gmail.com Will continued from page 80 McCormick Place Friday, April 20, 2012 8:00AM–4:30PM For registration, housing and program updates go to... www.CorneaDay.org 76-83 Cataract_EW October 2011-DL2_Layout 1 9/29/11 5:26 PM Page 82

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