Eyeworld

EW CATARACT 42 September 2015 by Ellen Stodola EyeWorld Staff Writer need to make sure that the patient is going to benefit," Dr. Chee said. The first step is perioperative management, which includes assessing the visual potential and risk for hypotony, assessing the need for perioperative steroids, and monitoring inflammation. Timing is also important, as is determining if an acrylic IOL is safe. The second pearl is to consider the small pupil. Release the peripheral anterior synechiae before the posterior syn- echiae, Dr. Chee said. Use intraca- meral balanced salt solution with epinephrine, then OVD, stretch the pupil, and do a sphincterotomy if necessary, she said. Avoid stretching an atrophic iris because it can rip. Next, Dr. Chee recommended removing the pupillary membrane. Release the pupil with dispersive OVD and a Kuglen hook, she said. Always remove the pupillary mem- brane to facilitate pupil expansion. "If the pupil doesn't expand well, you might have to use other pupil expansion devices," she said. The fourth pearl related to these small pupil devices. For an eye with a shal- low anterior chamber and small pu- pil, iris hooks may be a good option. For a deep anterior chamber that is not atrophic or scarred, a Malyugin ring or Beehler pupil dilator may be useful. Dr. Chee did not have a fifth pearl because she said that uveitic cataracts are quite simple to handle. In conclusion, she said that small pupils can be enlarged by releasing synechiae, removing membranes, or by being stretched or cut. Pre- and postoperative control of inflamma- tion is crucial to achieving a good visual outcome in uveitic eyes, she said. Fuchs' and cataracts Charles McGhee, MD, PhD, Auckland, New Zealand, offered pearls for cases of Fuchs' corneal dystrophy and cataracts. The first Small pupils and IFIS Grace Sun, MD, New York, shared 5 tips for dealing with small pu- pils and intraoperative floppy iris syndrome (IFIS). First, she offered a tip that she learned from one of her mentors, Alan Crandall, MD: "Don't be a cowboy. There's no ego in patient care. When you think you can get away with not doing some- thing, you may get lucky . . . but not always," she said. Instead, you should think like a Boy Scout and "be prepared." "There are several eti- ologies for a small pupil," she said. "Understanding them and knowing what tools you may need will make the surgery much smoother." The second pearl was to "use drugs," and Dr. Sun mentioned intracameral epinephrine, Shugarcaine, and intracameral xylocaine-dilute phenylephrine. The next pearl focused on the invaluable tool of viscoelastics. Dr. Sun said she uses both types for small pupil cases, dispersive and cohesive, to maxi- mize their unique properties. "Master rheology," she advised for her fourth pearl. "A lot of phaco is about fluidics." The anterior chamber must be stable, she said, and you want a small, tight incision so you don't have fluid pouring out of the wound. Machine settings are also important, and Dr. Sun suggest- ed decreasing the vacuum and flow rate and lowering the bottle height. Her last pearl was to "use devices" such as iris expansion devices and other mechanical techniques to in- crease pupil size. She concluded that sometimes no matter how much you prepare, things might not turn out as ideal as you would like. She offered this additional pearl as a sur- geon and for everyday life, "Forgive yourself every evening, recommit every morning." Phaco in uveitis Soon Phaik Chee, MD, Singapore, spoke about phaco in uveitis. "Be- fore bringing a patient to surgery, we pearls for this situation. First, he said to use a 5-mm capsulorhexis. Using anything smaller than this will make the epinucleus removal difficult, but a larger size will make optic capture difficult. Secondly, he recommended a hydro-free capsule cortical dissec- tion, which can make epinucleus re- moval easier. Dr. Bhattacharjee then said to do inside-out hydrodelinea- tion. This provides for endonucleus removal without threatening the PC. The next pearl was to use low parameters, slow phaco, and to maintain the AC. Dr. Bhattacharjee recommended having contingency plans in case of a PC rupture. Expect the best, but be prepared for the worst, he said. Surgeons discuss complicated cases in a symposium at the 2015 APAO Congress D uring the 2015 Asia-Pacific Academy of Ophthalmolo- gy (APAO) Congress earlier this year in Guangzhou, China, presenters in the "Complicated Phaco Cases" sympo- sium offered their top 5 pearls for dealing with a variety of issues. Posterior polar cataracts Suven Bhattacharjee, MD, Kolkata, India, showed a video of a posterior polar cataract to illustrate his top Pearls for complicated phaco cases continued on page 44 Dr. McGhee shares pearls for cases of Fuchs' dystrophy and cataracts.

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