Eyeworld

EW CATARACT 28 October 2015 complex cases can be challenging but "with proper planning, they can be safely performed oftentimes with a minimal amount of extra effort." Communicate with the patient and stay calm, he said. EW Editors' note: Dr. Davidson has finan- cial interests with Carl Zeiss Meditec (Jena, Germany) and Alcon (Fort Worth, Texas). Contact information Davidson: Richard.Davidson@UCDenver.edu by Ellen Stodola EyeWorld Staff Writer Finally, Dr. Davidson highlight- ed some concerns for postopera- tive recovery in these patients. Be prepared and prepare the patient for more corneal edema and intraocular inflammation, he said. If the patient has a history of uveitis, he recom- mended considering preoperative oral steroids or frequent topical ste- roids, considering a higher potency steroid, and considering postopera- tive sub-Tenon's steroids early if the inflammation does not subside as expected. In conclusion, Dr. Davidson said that white cataracts and other C omplex cataracts can be tricky for surgeons han- dling these cases. In a ses- sion at the 2015 Combined Ophthalmic Symposium, Richard Davidson, MD, Aurora, Colo., highlighted complex cata- racts in his talk and how to manage these patients. There are a variety of complex cataracts, and all of these pose challenges, especially white cataracts. White cataracts make the capsulorhexis difficult, have a dense nucleus, and the risk of complica- tions is higher. However, there are techniques and devices that can be used to effectively deal with these cataracts, he said. Preoperative evaluation is extremely important, Dr. Davidson said. "It's very important to document everything during this process," he said. Check for ocular comorbidities and document all conversations that you have with the patient. Surgeons will also have to decide whether it is best to use ECCE or phaco in these cases. Modern phaco machines allow the ability to perform phaco on most Tips for handling white cataracts T he white dense cataract can some- times have surgeons seeing red, due to the many intricate nuances in dealing with these complex cases. Richard Davidson, MD, gives us some tips and tricks for dealing with these tough cases— from proper preoperative assessment and planning, to having the right armamentari- um of tools in the OR, to having the correct discussion with your patients. He gives us the confidence to proceed without feeling intimidated by the surgical complexity of this cataract, as when all is said and done, these are some of our happiest patients. Rosa Braga-Mele, MD, MEd, FRCSC, cataract editor A white cataract as viewed after a femtosecond laser treatment has been applied and the lens capsule has been stained with trypan blue Cataract editor's corner of the world cataracts. Factoring in when it's best to fit these cases into a surgeon's day is also important. Dr. Davidson recommended that the surgeon per- form complex cases at the beginning or end of the day since they could be more difficult and take more time. Make sure the OR staff has everything available that you need prior to starting the case, Dr. Davidson said. This could include trypan blue dye, capsular tension rings, capsular support hooks, sutures, and IOLs of choice. Be sure to stay calm, and remember that the patient is awake, he said. If the surgeon is not calm, this could cause the patient to get anxious. Intraoperative techniques are important to consider when han- dling these complex cases. Visualiza- tion of the clear anterior capsule is more difficult, Dr. Davidson said. A white cataract can be partially lique- fied in the capsular bag. There may be leakage of white milky fluid, so decompress first, he said. It's also im- portant to keep the pressure in the anterior chamber greater than that in the capsular bag. To do this, use smaller incisions, cohesive viscoelas- tic, and micro-instrumentation. There are special considerations for patients post penetrating kera- toplasty (PK). Make sure all sutures are removed, Dr. Davidson said. Also be sure that the wound is stable, the refraction is stable, and there is no evidence of inflammation or rejec- tion, he said. Dr. Davidson prefers arcuate incisions over toric IOLs. Complex cases require special considerations during phaco because the density of the nucleus requires increased phaco power levels and higher duty cycle settings. Consid- er adding longitudinal phaco and watch carefully for wound burns, Dr. Davidson said. The posterior plate is often fibrous or leathery, which makes chopping or splitting the lens more difficult. Remember to protect the endothelium with additional vis- coelastic during surgery, he recom- mended. The Argentinian flag sign that can occur, most commonly with manual cataract surgery Source: Richard Davidson, MD

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