Eyeworld

EW MEETING REPORTER 124 Reporting from the 28th APACRS annual meeting, August 5–8, Kuala Lumpur, Malaysia Dr. Pangputhipong described his journey from phaco novice to expert and outlined the techniques he has mastered—and invented—to deal with complicated cataract cases. Dr. Pangputhipong highlighted the cataract extraction techniques he has learned and taught as the field has evolved from intracapsular cataract extraction (ICCE) to ECCE to phaco and finally to femtosecond laser-assisted surgery over the past 25 years—and showed how he plans to continue learning and teaching beyond day 8,760. Cataract surgeons in Thailand are plagued by several challenges, Dr. Pangputhipong said. The nature of cataracts in the region is different than in other areas of the world— the patients he sees most often have hard, white, mature, or brunescent cataracts that are difficult to operate on. In addition, in the early days of phaco, the techniques and technolo- gies available to Thai surgeons were not as developed as those available elsewhere and the training was severely limited. Because of these difficulties, Dr. Pangputhipong became an expert in nuclear disassembly methods and managing complicated cases. He has since imparted the wisdom of 25 years of phaco experience to the next generation of ophthalmologists in the Asia-Pacific region. The first strategy he mastered was bevel-down grooving, which is particularly useful for cases of hard nuclei and loose zonules. With the bevel down, he explained, emulsifi- cation is enhanced by the vacuum and less ultrasound energy is needed to break up the nucleus. Bevel-down grooving also protects the corne- al endothelium by projecting the ultrasound energy downward and facilitates working close to or under the iris without damaging it. One of the most important learning experiences that Dr. Pangputhipong imparts to the younger generation of surgeons is understanding nuclear disassembly techniques. There are 3 ingredients of nuclear division, he said—chop, groove, and crack—and these 3 ingredients can be combined in many ways to disassemble a nucleus. His goal has been to teach young surgeons how to understand these ingredients well enough that they can develop their own techniques as needed. As the spectrum of nuclear disassembly techniques evolved and expanded, Dr. Pangputhipong ad- opted the methods that worked best for him and invented several others when existing techniques fell short. He developed a 3D cracking tech- nique that applies forces in a specific pattern, vertically and horizontally, to separate a hard nucleus with minimal force. He also developed a triangular cracking technique that can be modified for soft, medium, and hard cataracts. The technique involves making a triangular groove in the center of the cataract that is then used to split the nucleus into 3 pieces. This method minimizes the need for rotation of the fragments, adds room for manipulation, and allows for minimal hydrodissection. Around day 8,000—in 2012— Dr. Pangputhipong adopted fem- tosecond laser-assisted cataract surgery. But instead of abandoning the methods he had developed over the past 22 years, he simply adapted them, bringing the benefits of the old techniques to the new technol- ogy. Applying the principle of divid- ing a nucleus into 3 triangular pieces in his triangular cracking technique, Dr. Pangputhipong now uses the femtosecond laser to create an "X" pattern, breaking the lens into 4 triangular pieces. This method still has the benefits of minimal rotation and hydrodissection that triangular cracking had and is extremely quick, he said. For mature and hard cata- racts, he uses the femtosecond laser to create the capsulotomy and then continues the case with his 3D stop and chop phaco technique. CSCRS: Escape! the Event Horizon Despite even the most experienced surgeon's best efforts, situations can arise in which the surgeon might feel as though a gaping black hole has just opened up. And as with theoretical, astronomical black holes, these situations have event horizons—points of no return across which there is no recovering a case. With these situations often comes a feeling of "impending doom"—but don't fret! Experts at the Combined Symposium of Cataract and Refrac- tive Societies (CSCRS) have been there, done that, and are back to guide attendees through ways of avoiding crossing over the inescap- able event horizons of these black hole situations. One of these situations is infusion misdirection syndrome—a topic that Chee Soon Phaik, MD, Singapore, joked was also some- thing of a nightmare for her in terms of preparing for her lecture, owing to the paucity of published September 2015

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