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EW FEATURE 74 Complex cataract cases October 2014 Alcon, Fort Worth, Texas) to quell persistent postop inflammation for those who he thinks are not compli- ant with the Pred Forte regimen. Dr. Pettey waits between 8 and 12 weeks before he is willing to consider refer- ring a patient for DSEAK. Promising pearls To help ensure the best outcomes, Dr. Pettey recommends having a plan for different types of dense lenses. For any ultra dense lenses, he recommends use of trypan blue. This enables him to spot a capsule problem quickly. He also advises practitioners to have both a cohesive and a disper- sive viscoelastic on hand. "I'll use them very deliberately in the case depending on what the need is at the time, whereas in normal cases, I typically only use DisCoVisc [Alcon] or even an Amvisc [Bausch + Lomb, Bridgewater, N.J.]," he said. Meanwhile, Dr. Page prefers to use a truly dispersive viscoelastic in these cases to protect the endotheli- um. In normal cases, he usually uses a combined dispersive cohesive vis- coelastic at this stage. Because these dense cases tend to be a bit longer, he urges practitioners to frequently reapply the dispersive viscoelastic throughout the removal process because it can wash away. Dr. Page also stressed the im- portance of being careful of post occlusion as the dense lens can be larger than the average cataract. When using a peristaltic system to help combat this, he recommends dropping the volume down by 100 mmHg when working on the last nucleus segment. Going forward, Dr. Page is optimistic that removal of dense cataracts will become easier with the aid of the femtosecond laser. "Prob- ably one of its greatest applications would be in assisting us with dense nuclei," he said. In these dense cases, he tightens the fragmentation pattern from a standard of 500 µm down to around 250 or 300 µm to further soften the lens. "I think that's a significant contribution of the femtosecond laser," he said. EW Editors' note: Dr. Page has financial interests with Abbott Medical Optics (Santa Ana, Calif.) and Bausch + Lomb. Dr. Pettey has financial interests with MicroSurgical Technology (Redmond, Wash.). Contact information Page: TPageMD@yahoo.com Pettey: jeff.pettey@hsc.utah.edu as sutureless extracapsular cataract surgery. One potential concern with this approach is that the capsulot- omy does not have the consistent lens overlap that you can get with phaco, Dr. Pettey said. Also, because of the larger wound, the astigma- tism changes can be a little bit more variable, he finds There can also be complications using the ultrasonic prechopper. "We did a study here that showed that wound burn is certainly possi- ble with the prechopper," Dr. Pettey said. In cases of mild wound burn, a simple suture will suffice, he noted. However, if there is significant gape resulting in visually debilitating astigmatism, he recommends su- turing filler tissue such as amniotic membrane into the wound with the intention of sealing it. Then it is just a matter of the epithelium closing over the top. With dense lenses, one height- ened concern postoperatively can be corneal edema. Keeping this in mind, Dr. Pettey increases the fre- quency of Pred Forte (prednisolone acetate, Allergan, Irvine, Calif.) use in dense cataract cases. He also sometimes uses Durezol (difluprednate ophthalmic emulsion, milliseconds off, and that seems to allow for the most efficient phaco." In conjunction with this, Dr. Pettey likes to use an ultrasonic pre- chopper for most dense lenses. "This is a modified phaco tip with a sharp end that allows for the creation of very small grooves," he said. Use of the Akahoshi prechopper (Asico, Westmont, Ill.) enables the nucleus to be divided into 4 or 6 sections be- fore quadrant phacoemulsification, allowing for efficient removal. In cases where Dr. Pettey is concerned that the phaco energy is going to be too much for the endo- thelium or if the patient has Fuchs' dystrophy with a hypermature dense lens, he switches to manual small incision cataract surgery, also known way the phaco power is on a little longer but is still not continuous, thereby minimizing the amount of energy going into the eye. Dr. Pettey, likewise, makes some phaco adjustments with dense lenses. In particular he worries about zonulopathy. When dealing with morgagnian white cataracts that are hypermature and intumescent, Dr. Pettey lowers the bottle height and the aspiration rate. However, if it's just a dense lens, he does not alter fluidics but does make other adjus - ments. "If we're talking about just a 4+ dense lens, I'll increase both the power and the torsional energy," he said. "One thing I've also found helpful is to use a pulse modality of about 6 milliseconds on and 6 Cracking continued from page 72 Dense cataracts bring added risks for removal and can make it difficult to view the etina. Source: Timothy P. Page, MD EyeWorld @EWNews Keep up on the latest in ophthalmology! Follow EyeWorld on Twitter at twitter.com/EWNews