EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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83 EW FEATURE the eyelet with 9-0 Prolene or make a hitch around it with CV-8 Gore- Tex," he said. Dr. Afshari also likes the STAAR AQ2010 lens for scleral fixation with gluing of the lens. Sutures It is important to consider the types of sutures for these cases. For iris fixation, D . Lee uses a 9-0 Prolene suture on a long curved needle with a Siepser or McCannel knot, de- pending on where the incisions and suture passes are. For scleral fixation, he is transitioning from 9-0 Prolene to CV-8 Gore-Tex. "For both iris- and scleral-fixated IOLs, the MST snare [MicroSurgical Technology, Redmond, Wash.] makes retrieving sutures through a small incision easy," he said. Dr. Davidson said his choice for sutures depends on what is being done. He uses a 10-0 Prolene when he is suturing to the iris. For this, he also uses the CIF-4 needle, a long, curved needle. However, for suture fixation to the sclera, he prefers 8-0 Gore-Tex if it's available. Dr. Davidson noted that this would be off-label use, but the advantage is that this type of suture tends to not biodegrade. Dr. Afshari uses 9-0 Prolene in cases of sutured scleral fixation and 10-0 Prolene on CIF-4 needle for iris fixation of IOLs Postop medication regimen Dr. Davidson uses the same postop- erative medication regimen that he would use for cataract surgery. This includes an antibiotic 4 times a day, a nonsteroidal 4 times a day, and a steroid 4 times a day. "I'll use that for the first week and then taper the nonsteroidal and the steroid over the next 2 to 3 weeks," he said. The exact regimen will depend on the patient, the amount of inflamm - tion, the procedure, and any exist- ing issues the patient has. Dr. Lee uses a regimen of an antibiotic, steroid, and NSAID; however, he usually has his patients continue with these medications for several months after surgery. Dr. Afshari said that she also uses a combination of steroids, antibiotics, and NSAIDs. Steroid use varies for these patients, and the amount of corneal edema is taken into consideration. "I keep them on steroids longer than an average cataract patient because they have more of a complex surgery," she said. NSAIDs are often a helpful additional therapy in these patients because they have higher chances of developing macular edema with more manipulation compared to routine cataract surgery patients, Dr. Afshari said. Vitrectomy Surgeons need to consider how to proceed when performing a vitrec- tomy. In some cases, retina special- ists may assist, depending on the type of case. Dr. Davidson said that sometimes he performs anterior vitrectomies and sometimes he will do a combined case with a retina specialist. If it is truly just an ante- rior chamber problem but there is vitreous coming up into the anterior segment, he handles it. However, for issues like the lens dangling into the vitreous cavity or a lens that has fallen in back of the eye, he calls a specialist. "I usually do my own subtotal vitrectomy with infusion through a paracentesis and the vitrector through the limbus or pars plana," Dr. Lee said. "However, I'm fortu- nate to have retina colleagues who are available and willing to help if a complete vitrectomy is needed." Dr. Afshari said she will perform an anterior vitrectomy on her own. "If thorough vitrectomy is needed, I will do the surgery combined with a retina colleague who would perform pars plana vitrectomy." How to improve Reading articles, watching videos, and attending training sessions and courses are good ways of improving techniques for secondary IOL im- plantation, Dr. Afshari said. "Many of these cases are not routine," she said, so these are not necessarily procedures that physicians have experience with. "One great way to get experi- ence with iris suturing is to start EyeWorld Monthly Pulse EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthalmologist. Each month we send an online survey covering different topics so our readers can see how they compare to our survey. If you would like to join the hundreds of physicians who take a minute a month to share their views, please send us an email and we will add your name. Email carly@eyeworld.org and put EW Pulse in the subject line—that's all it takes. Poll size: 274 October 2014 Complex cataract cases with pupilloplasties, perhaps on your cataract patients who have intraoperative floppy iris syndrome," Dr. Lee said. "Certainly if you have access to a wet lab, it's very helpful to go and practice suturing if you haven't sutured for a while," Dr. Davidson said. It's also useful to watch videos. Memorizing the procedure ahead of time is helpful, Dr. Davidson said, because it helps to be able to visualize what to do so you are not trying to remember the next step during the surgery. Performing a number of surger- ies in a short time helps one become familiar with the procedure, as does having an assistant help while you are learning the technique. Dr. Davidson added that it is im- portant to be familiar with a number of techniques for secondary IOLs. "I don't think there's one tech- nique that's good for every patient," he said. "You have to have several techniques in your armamentarium so that you can customize it depend- ing on what that patient's needs are and what the patient's anatomy is like." EW Editors' note: Drs. Davidson, Afshari, and Lee have no financial interests related to their comments. Contact information Afshari: naafshari@ucsd.edu Davidson: Richard.Davidson@UCDenver.edu Lee: leemd@uw.edu