Eyeworld

EW RESIDENTS 100 February 2015 the machine settings since high fixed aspiration flow rates can create a fast current in the AC with fast movement of the nuclear pieces. Close evaluation of the removal of the last few nuclear chips is im- portant. This is when the posterior capsule is no longer being held back and protected by nuclear pieces. This combined with post-occlusion surge that causes a temporary shal- lowing may be enough to cause the TORIC/LRI MARKERS S9-2033 Pre-Operative Alignment Marker For marking patient on gurney or at slit lamp prior to procedure • Three fine marking points at 3, 6 and 9 for accurate reference • Properly angled handle allows an unimposing approach to patient S9-2060 Mendez Style Degree Gauge Intra-operative ring for aligning to steep axis and defining LRI points • Large 11.7mm internal diameter provides for maximum visualization • Beveled surface reduces reflections form microscope lighting • Crisp laser etched markings every 5˚ for greater marking accuracy S9-2065 Axis Marker Works inside the Degree Gauge to mark prime meridian (steep axis) for LRIs and Toric alignment. • Fits inside Degree Gauge perfectly • Crisp edges create a fine demarcation • Length of marks accommodates both limbal and corneal marking S9-2050 LRI Marker Provides crisp marks at commonly used LRI Positions • Fits inside Degree Gauge perfectly • Creates symmetrical, opposing marks for 30˚, 45˚ and 60˚ incisions • Fine arc connects degree endpoints for easy, acurate incisions 2500 Sandersville Rd., Lexington, KY 40511 USA Phone: 800-354-7848, 859-259-4924 Fax: 859-259-4926 E-Mail: sales@stephensinst.com www.stephensinst.com Visit Us at ASCRS Booth #2225 Leave it or tear it continued from page 99 movement of the posterior capsule forward into the phaco tip. If this is indeed the case, it can be useful to reduce the aspiration flow rate to slow the movement in the AC. Lowering the vacuum will reduce post-occlusion surge, and some like to use a blunt smooth second instru- ment behind the phaco needle to protect the posterior capsule. Others use the second instrument to gently tease the nuclear tip off the phaco tip to prevent complete occlusion and vacuum buildup. Finally, if the current in the anterior chamber moves nuclear chips close to the main incision, it is best to push the chips more central before trying to grab them with the phaco needle. If the incision is distorted or the phaco tip is slightly withdrawn, it may cause acute shal- lowing of the chamber with anterior movement of the posterior capsule, risking capsule rupture by the phaco tip. This is because the irrigation ports are higher up on the phaco handpiece and moving to grab the nuclear chip in this awkward man- ner may move the irrigation into the wound, causing redirection of the fluid out of the eye. Again this creates a drop in chamber pressure, allowing the posterior capsule to move forward. To avoid this one can push the final pieces back into the center of the eye and keep the phaco needle in the eye. Finally, if the tear happened during the I/A with no obvious ex- planation, we need to consider the tip may have a sharp irregularity. Shahzad I. Mian, MD Associate chair of education, residency program director, Department of Ophthalmology, University of Michigan, W.K. Kellogg Eye Center, Ann Arbor, Mich. Posterior capsular tears caused by contact between the phaco hand- piece and the posterior capsule often occur as the last nuclear quadrant is removed or during epinuclear re- moval. Essential steps in prevention start early in the case with creation of beveled incisions in order to minimize leakage of fluid during the case and maintain the anterior chamber. A complete hydrodelin- eation allows the epinucleus to protect the posterior capsule during phacoemulsification, including sculpting. During quadrant removal or chopping, pulling the nuclear pieces up to the anterior capsular space maintains a safe distance from the posterior capsule. When remov- ing the last nuclear fragment, it also helps to keep the chopper or spat- ula under the nuclear fragment to prevent the posterior capsule from contacting the phacoemulsification handpiece. If the posterior capsular tear has a flap, the tag can be converted to a continuous capsular opening. This can help prevent radialization during residual cortical removal and lens placement. If the posterior cap- sular opening is central, small with no significant degree of additional cortical cleanup required, the cap- sular tear may be left alone without any sequelae. IOL placement in the capsular bag is preferable. This allows for better control over the effective lens position and final refractive outcome. The lens is more stable in the capsular bag and may prevent vitreous prolapse during viscoelastic removal. The IOL may also be placed in the sulcus with optic capture with the anterior capsule. Using a 3-piece IOL is preferable over a 1-piece IOL in case the lens is not stable when placed in the capsular bag. EW Contact information MacDonald: Susan.M.MacDonald@lahey.org Mian: smian@med.umich.edu Springs: csprings@iupui.edu

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