Eyeworld

121 September 2015 EW MEETING REPORTER 'Misadventures,' MSICS among new MasterClasses MasterClasses offered for the first time at this meeting focused on complications during cataract surgery and the essential but often overlooked technique of manu- al small incision cataract surgery (MSICS). There are 2 surefire ways to avoid complications during cat- aract surgery, according to Arup Chakrabarti, MD, Kerala, India: not operating at all and living in denial about complications. Dr. Chakrabarti was speaking to a roomful of cataract surgeons at "Phaco Misadventures," one of the new MasterClasses. The MasterClass covered 7 types of "misadventures": phaco burns, capsular mishaps, open posterior capsule situations, iris prolapse, zonular loss, IOL rescue, and "pot- pourris" of complications. Dr. Chakrabarti presented one of his own cases of phaco burn. In what would otherwise have been a routine case, the fluid infusion had stopped, filling the anterior chamber with air bubbles instead of balanced salt solution. Dr. Chakrabarti said that air bubbles occur sporadically in routine cases, and are generally absorbed during phaco. He had not taken into account the possibility of what actually occurred in this case: The phaco handpiece had com- pletely dried out. Without fluid to dissipate the heat generated by the handpiece, phaco caused a burn at the incision. Dr. Chakrabarti managed the case by migrating superiorly to cre- ate a new corneal incision through which to continue the procedure. The additional incision meant that he had to be careful not to al- low the anterior chamber to shallow. Frequent injections of dispersive OVD avoided further complication. Finally, Dr. Chakrabarti augmented the leaky phaco burned incision with sutures. Initially, the patient experienced high astigmatism postop, but the astigmatism eventually went down and the patient's visual outcomes were otherwise good. Dr. Chakrabarti went on to describe 3 cases in which the sur- geon should be particularly vigi- lant against phaco burns. First, in patients with deep set eyes, surgeons should approach from the tem- poral side to avoid a too-vertical placement of the phaco handpiece. Second, the presence of cloudy lens milk in the anterior chamber suggests aspiration is not sufficient; therefore, aspiration might also not be sufficient for heat dissipation. In these cases the surgeon should increase aspiration. Finally, as in Dr. Chakrabarti's case, surgeons should be wary of occlusion blockage. A second new cataract surgery MasterClass highlighted an often overlooked technique in cataract surgery. More than just an "alternate to phaco in many communities," Sanduk Ruit, MD, Kathmandu, Nepal, said that the technique— manual small incision cataract surgery (MSICS)—should be a man- datory skill for cataract surgeons in addition to phaco. The technique, he believes, is necessary to address global cataract blindness. While cat- aract surgery rates (CSR) around the world are "actually getting better," Dr. Ruit estimated the cataract back- log to be about 121 million operable cataracts. This, he said, combined with other challenges both intrinsic (stage and complexity of cataract, capsular changes, varieties of nu- cleus, zonular status) and extrinsic (work conditions, team, equipment and instrumentation, volume) to cataracts, as well as the fact that the technique helps surgeons learn and develop skills that can aid in the management of special situa- tions during cataract surgery, makes MSICS an essential skill for cataract surgeons. The MasterClass detailed the technique in all of its steps: wound construction, capsulotomy, nucleus delivery, lens implantation, and, in Dr. Ruit's particular variant of the technique, capsulectomy. Current and new options for glaucoma surgery Glaucoma was a major focus of the first day of programming, with different surgical procedures dis- cussed in a symposium that touched on filtering surgery, trabeculectomy, and other related topics. Sir Peng Khaw, MD, London, gave a lecture focusing on surgery for glaucoma. His lecture, "Strategies and Techniques to Improve Out- comes of Glaucoma Filtering Sur- gery," highlighted wound healing, among other important factors in surgery. Wound healing is the most important thing in determining whether or not your surgery suc- ceeds, Dr. Khaw said, and scarring is the major barrier to success. One issue that is particularly puzzling, he said, is why some peo- ple scar more. If you look at biopsies of conjunctiva and gene expression, we all differ, he said. "The one message to get out of this is the fact that there are a lot of things that go on," Dr. Khaw said. "And that's the problem with wound healing and scarring: It isn't just one thing; it's multiple things." The other issue is ethnicity does have an effect on wound healing. "We've been trying to work out for a long time why peo- ple who are darker heal more quick- ly than people who are lighter." Dr. Khaw highlighted the im- portance of identifying and treating "red eyes." The longer the eye has been red, the more likely it is that the bleb will fail so addressing this problem is important. He recom- mended several options for treating red eyes, like steroids, NSAIDs, or oral steroid or NSAID treatment. New generation steroid-like agents are coming, he said. View videos from Thursday at APACRS: EWrePlay.org Y.C. Lee, MD, Kuala Lumpur, Malaysia, describes a technique for managing ectopia lentis using flat retractors. continued on page 122

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