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EW MEETING REPORTER May 2014 61 management of mature cataracts. She stressed her methodical ap- proach to this issue in patients. When we think about mature cataract, she said, we may have a little bit of anxiety when looking at these patients. She questioned whether this was a valid concern and whether mature cataracts truly do have a higher complication rate. She discussed how not all white cataracts are the same. They can be classified as hard, traumatic, Morgagnian, intumescent, or white cortical cataracts. "Don't make as- sumptions about the cataract," Dr. MacDonald said. "Be prepared for everything." She also stressed that it is impor- tant to use dye on mature cataracts. This will help to make the surgeon's view better, and it will also make the case easier and more efficient and can create a better outcome for the patient. Dr. MacDonald said that when working on mature cataract cases with her residents, she is always sure to encourage practice of rescue maneuvers in every case in order to ensure that they are not hesitating. "It's the hesitation that gets everyone into trouble," she said. Dr. MacDonald discussed wound manipulation in these cases. This can open the wound, allow for decompression of the anterior cham- ber, allow for movement of the lens iris diaphragm, and increase the doming of the lens. The final issue that she dis- cussed with mature cataracts is that they can be very dense and require a lot of power. Dr. MacDonald likes to use the quick chop technique. She also uses burst mode, as well as mul- tiple cracks on a single chop moving toward the posterior capsule. She debulks the nucleus in the capsule and uses power modulation burst or pulse mode. To conclude her presentation, Dr. MacDonald stressed again the importance of developing a routine for difficult cases. Hadi Prakoso, MD, Indonesia, discussed the topic of brunescent and black cataracts, which he said remain a great challenge to phaco surgeons. There are potentially dev- astating complications associated with these cataracts, like severe endothelial loss leading to bullous keratopathy that needs PKP, wound burn, zonular loss, PCR, and vitreous prolapse and nucleus drop. Dr. Prakoso said that the ques- tion to consider is which procedure is really better for this situation: phaco or extracapsular cataract extraction (ECCE)? He said that ECCE looks like a better option in terms of less chance of complica- tions, but there is also slower visual recovery, wider wounds, stitches, higher surgically induced astigma- tism, and there is still a possibility of posterior capsular rupture with vitre- ous prolapse. Phaco is the procedure of choice in modern cataract sur- gery, he said, but surgeons still need to decide if they want to use it in a very hard cataract case. "The cortex usually becomes so hard, and the further you go to the center, the harder the nucleus is," Dr. Prakoso said, highlighting the best way to demolish the nucleus. He said it is important to start with the center, or hardest part, by creat- ing a deep and long groove at the deepest part of the nucleus. Destroy the hardest part and leave only the thin wall above and beneath and then you can divide nucleus, he said, indicating that he prefers the vertical chop over the horizontal chop to divide the nucleus. Richard Packard, MD, U.K., discussed surgical challenges that are associated with highly myopic and vitrectomized eyes. "High myopia can present major challenges for cataract sur- geons especially if the patient has already had refractive surgery," he said. Factors to take into considera- tion include the biometry; the lens availability for extreme sizes and power of presbyopic correction desired; the type of anesthesia to be used; surgical considerations because of the anterior chamber depth and large eye in deep orbit; and the inci- sion size and machine settings. Most would agree that peri- and retrobul- bar anesthesia is not recommended in these eyes, Dr. Packard said. He would recommend topical anesthesia. Other topics he discussed were how to prepare the patient for sur- gery, which includes carrying out a careful preoperative retinal evaluation looking for predisposing lesions, and using machine settings to avoid chamber instability. All about angle closure Angle closure glaucoma varies in prevalence around the world, even in populations of similar ethnicity, but a high rate of blindness associ- ated with the condition makes it a concern anywhere it occurs, said experts at an "Update on Primary Angle-Closure Glaucoma" sympo- sium. Beginning with the basics, Kyung Rim Sung, MD, South Korea, discussed the sub-classification of primary angle closure glaucoma (PACG). Broadly, angle closure is classified according to time profile CATz, our latest innovation in Laser Vision Correction, enables surgeons to treat myopic astigmatism with corneal irregularities. CONTACT NIDEK TO ELIMINATE YOUR USER FEES TODAY! 130%6$54t4&37*$&4t5&$)/0-0(*&4 continued on page 62

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