Eyeworld

125 September 2015 EW MEETING REPORTER Reporting from the Date AAAA City, Country information. Infusion misdirection syndrome is the sudden, dramatic, and persistent shallowing of the an- terior chamber characterized by the absence of choroidal hemorrhage or external pressure that usually occurs during irrigation/aspiration or irrigation of the posterior capsule during cataract surgery. The patho- physiology is unclear, although Richard Mackool, MD, who coined the term, described infusion fluid accumulating in the potential space between the posterior capsule and anterior vitreous. This seems to take place despite an intact posterior capsule, but is postulated to result from anterior hyaloid membrane detachment or tear. Dr. Chee cited a prior study that identified prolonged irrigation and deflation/inflation of the anterior chamber as a risk factor for anterior hyaloid membrane detachment, while 27-G hydrodis- section is a risk factor for anterior hyaloid membrane tear—turning the potential space between the mem- brane and the posterior capsule into a real space. Dr. Chee has observed infusion misdirection syndrome occurring with forceful rotation of the nucleus with ineffective hy- drodissection. Mild cases can be managed by watching the posterior capsule closely during irrigation/as- piration and IOL insertion. Surgeons should also be careful when remov- ing OVD from under the IOL. Dr. Chee manages moderate cases by running IV mannitol as quickly as is safe and waiting for the misdirected fluid to egress. External pressure is reduced by loosening the speculum, through topical anesthet- ics and sedation (as misdirection syndrome is uncomfortable for the patient). The surgeon should then gradually deepen the anterior with retentive OVD until the posterior capsule moves posteriorly. The IOL should be inserted carefully, and care should be taken when removing OVD from under the IOL. In severe cases, choroidal hemorrhage needs to be excluded. Dr. Chee aspirates the trapped retrolenticular fluid through 25-G pars plana needle aspiration and performs a 23- or 25-G limited anterior vitrectomy. The syndrome can be prevented by performing gentle but adequate hydrodissection, avoiding pro- longed irrigation, avoiding repeated deflation/inflation of the anterior chamber, and being on alert in high- risk eyes such as those with weak zonules. SICS—what's best for the patient? Almaha, a young mother widowed during the Ethiopian-Eritrean War, developed cataracts from injuries and subsequently came under the View videos from Friday at APACRS: EWrePlay.org Edgar Leuenberger, MD, Makati City, Philippines, describes his study on creating scleral flaps using the femtosecond laser. continued on page 126

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