EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/422211
67 December 2014 EW MEETING REPORTER the pars plana, and out through the sclera. The technique thus literally fixes the bag—with IOL inside it— to the wall. The full procedure was published in Annals of Ophthalmology. Tips for achieving precision in cataract surgery highlighted A symposium on Thursday, Nov. 13 provided an update on management of complications. It focused on ways to achieve precision in cataract sur- gery, with each presentation offering tips on dealing with one specific topic or issue. Pravin Vaddavalli, MD, Hyderabad, India, discussed cataract surgery in extreme corne- al ectasia. He highlighted several specific cases where he dealt with this issue. The first was a 64-year- old woman whose surgery first began as a routine cataract surgery. However, when doing the surgery it became necessary to suture the wound because it had extended from significant leakage. When looking at the patient postop, it be- came clear that she had a very thin cornea, with OCT indicating that she had only about 300 microns of corneal thickness in the periphery. However, she had seemingly normal topography. "Typically keratoglobus, which is what we diagnosed her with, presents in children," he said. Keratoglobus is rare and may be associated with systemic features, Dr. Vaddavalli said. "Always assess the corneal thickness on slit lamp," he said. When making side ports, start on the sclera. IOL power calculation is difficult in these cases, he added. Athiya Agarwal, MD, Chennai, India, discussed "glued IOL in a sticky situation," highlighting pre-Descemet's endothelial keratoplasty (PDEK). She showed a case of this that used do- nor tissue from a 9-month-old eye. PDEK is an interesting alternative to the DMEK and DSEK procedures. Dr. Agarwal cited Harminder Dua, MD, Nottingham, U.K., and Dua's layer. In addition to the 5 basic layers in the cornea, there is one more, Dua's layer, which is about 10 to 15 mi- crons thick and located between the Descemet's membrane and the stro- ma. Gently try to inject air between the Descemet's membrane and Dua's layer, she said. This will create a type-1 bubble, and you can take a knife and go inside. After staining, cut the graft. A DMEK graft is very fragile and difficult to handle. But in PDEK, Dr. Agarwal said, it's easy to handle because you have addi- tional microns. "And it gives more strength to the patient's eye," she said. Additionally, an advantage of PDEK is that younger donors can be used. "If you want to take a graft for DMEK and DSEK, you have to use old donors." With PDEK and young donors, tissue handling is easier. Dr. Agarwal showed a video of using a PDEK graft. She loaded the graft into an injector and slowly injected it into the anterior cham- ber. The beauty of the graft is it is 25 to 30 microns thick because there is an additional layer, she said. After injecting it, roll the graft and center it. "Air has to be constantly injected inside the eye," Dr. Agarwal said. Postoperative results were extremely good. After just one day, the cornea was clear and OCT was good. Dr. Agarwal noted that handling Dua's layer does require some practice. You have to learn how deep to go using the 30-gauge needle, she said, and it's important to practice how to inject air to create a type-1 bubble. Amit Porwal, MD, Indore, India, highlighted in his presen- tation some important pearls for dealing with the Argentinian flag sign. "Use a high-density viscoelastic substance," he said. It's also import- ant to maintain anterior chamber depth adequately. "Always stain the anterior capsule." Decompress the intralenticular pressure, and proceed with a 2 stage rhexis. Finally, he said to "practice performing the rhexis with both the hands." Haripriya Aravind, MD, Madurai, India, spoke on the topic of posterior capsule rifts and nucleus drifts. She talked about a patient who had phacoemulsification per- formed on a brown cataract. Before nucleus prolapse the iris was opened up and nucleus collapse was at- tempted, she said, but the rhexis was not of adequate size for prolapsing a nucleus into the anterior chamber. The rhexis was intended for pha- co and the pupil was small. When trying to manipulate a nucleus out through a small rhexis and small pupil, the pressure is more in the posterior capsule. With a preexisting tear, it will only increase in size, and this could cause a dislocated nucle- us. When you're trying to collapse a nucleus in a compromised capsule, you want the pathway to be large enough, Dr. Aravind said. You want to have a large enough rhexis, a large pupil, and the wound has to be the right size, she said. When the whole pathway is widened, it is safer to prolapse it. Surgical pearls for management of cataract complications A symposium discussed the man- agement of complications during cataract surgery. Paul Ursell, MD, London, offered pearls for managing IOLs that become incarcerated in the wound during implantation. The take-home message, according to Dr. Ursell, is to pull the IOL out of the wound rather than pushing it in. An incarcerated lens can be damaged by the process of extraction, he said, so it is best to pull the lens out and inspect it for damage rather than im- planting it as is. When pulling the lens out, the surgeon can get count- er traction on the wound by having the patient fixate on the light. If this does not work, enlarge the wound to facilitate pulling the lens out. After extracting the lens, inspect both the lens and the integrity of the incision. These wounds will always need to be sutured, Dr. Ursell said, because they have been traumatized. Hadi Prakoso, MD, Jakarta, Indonesia, offered pearls for avoid- ing and managing iris prolapse in intraoperative floppy iris syndrome (IFIS) cases. It is important not to overfill the anterior chamber with viscoelastic, Dr. Prakoso said, be- cause the pressure of the OVD will cause it to slip beneath the iris and push it from the chamber. Excessive viscoelastic can also put pressure on the iris root, which can raise the iris and cause it to prolapse. As an alternative, place the OVD on top of the iris surface to close the space between the iris and the lens. continued on page 68 View it now: APACRS 2014 ... EWrePlay.org Warren Hill, MD, summarizes his Lim Lecture on the latest innovations in IOL calculations.