EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/422211
EW MEETING REPORTER 68 December 2014 Reporting from the 2014 Asia-Pacific Association of Cataract & Refractive Surgeons annual meeting, Jaipur, India Additionally, during phaco, put the machine on low settings, Dr. Prakoso said, because turbulence can push the iris out of the chamber. Avoid pressing on the sclera and perform every maneuver carefully. Turgid white cataracts are still a challenge for even the most experi- enced cataract surgeons, said Sanjay Chaudhary, MD, New Delhi, India. In these cases, high intralenticular pressure can easily cause a rhexis to tear and extend into the periphery. The speed at which the tear extends to the equator can rip the posterior capsule and force the nucleus into the anterior chamber, he said. To manage these situations, Dr. Chaudhary recommended that surgeons first make a small capsulor- hexis that will better resist tearing, release the pressure in the bag, and then make a small nick and extend the rhexis to the desired size. "Even in the best of hands, you can never predict what is going to happen in a turgid white cataract," Dr. Chaudhary said. The ideal solution is to have a method of creating the capsulorhexis that will always work, and for him, that solution is to use the femtosecond laser. The first surgeon to perform femto cataract surgery in India, Dr. Chaudhary thinks a rhexis made by a femtosec- ond laser will always deliver the best and most consistent results. Namrata Sharma, MD, New Delhi, India, discussed methods for managing Descemet's membrane detachment (DMD) during cata- ract surgery. Pre-existing corneal endothelial disease such as Fuchs' dystrophy can predispose patients to DMD, Dr. Sharma said, so in these cases, plan to use superior clear cor- neal or scleral incisions. To manage DMD intraoperatively, Dr. Sharma recommended minimizing manipu- lations and using an air tamponade to reattach the membrane to the overlying stroma. Touch the iris to know you're in the correct plane, and inject the air bubble as one bolus from a side port. Anterior segment OCT is a useful tool in these situations, Dr. Sharma said, because it can help guide treatment. Update on management of complex cases It started, as these cases do, in a very unusual way," said Eric Donnenfeld, MD, Rockville Centre, N.Y. Dr. Donnenfeld presented a case of complex cataract management— one that he called "a full fellowship in one case." It began with a referral. A colleague had been treating a patient for a corneal ulcer for some time. Eventually, the colleague called on Dr. Donnenfeld. By then, the ulcer had progressed to a 6-mm perforation. The iris was incarcerat- ed in the lesion, the IOP was 35 mm Hg, and there was no anterior cham- ber. Dr. Donnenfeld first performed a partial trephination to remove the affected corneal tissue. He was confronted with the problem of how to create an anterior chamber. He threw the question to the symposium's chairs. Abhay Vasavada, MD, Ahmedabad, India, responded. "I must confess in this case the examination papers had been leaked. In this case, you perform a pars plana vitrectomy." Dr. Donnenfeld did indeed perform pars plana vitrectomy and having removed the vitreous, thus relieving pressure from the poste- rior chamber, the anterior cham- ber effectively dropped open. He stripped away the necrotic tissue and inflammatory membranes. From there he could proceed with cataract extraction. Because there was no pressure from the posterior chamber, Dr. Donnenfeld had to create pres- sure by pressing on the eye to keep the lens from dropping. He proceed- ed to harpoon the lens and extracted the cataract. He implanted a 3-piece IOL and performed a straightforward penetrating keratoplasty. That left one more question: Why did the patient develop microbial keratitis in the first place? Moreover, why was it unresponsive to treatment? Now that he could pull his focus back from the cornea and anterior chamber, Dr. Donnenfeld was able to consider the patient's eye more comprehensively. He realized the patient had floppy eyelid syndrome—a condition character- ized by flaccid, easily everted lids. He surmised that the eyelid's propensi- ty for both eversion and inversion must have resulted in repeated trauma to the corneal surface, preventing the corneal ulcer from healing. He performed a tarsorrhaphy. Only then was Dr. Donnenfeld satisfied that he had solved all the patient's problems. In India, Dr. Vasavada said, similar cases of intractable corneal surface infection are usually caused by chronic nasolacrimal occlusion. Highlighting the significance of regional variations, Dr. Donnenfeld said that this is not typically the case in the U.S., as it was not the case in this patient. APACRS held a special dinner at the Raj Palace Hotel on Thursday, November 13. Supported by