Eyeworld

EW CATARACT 40 October 2015 In the "Other" category, re- sponses were needle stromal injec- tion on roof of incision, no steps whatsoever, and combination of "Wong" and internal hydration. The second question was, "How do you test to assure that the incisions are watertight when the patient is on the table?" by Mitch Gossman, MD formed. Painting with dry fluores- cein for a Seidel test revealed that the paracentesis, created with a 1.0 mm diamond blade, indeed had a small leak. This was managed with aqueous suppressant and a bandage contact lens, and it was sealed the next day. I asked the co-managing optometrist how she noticed this and she said Seidel test revealed it. I asked what prompted the Seidel test, since I noted nothing con- cerning, and she said that she tests the incisions routinely with Seidel testing. This piqued my interest as to how ophthalmologists check their incisions, both on the table and postoperatively, how ophthal- mologists check intraocular pressure on the table, and how incisions are being sealed. A survey was performed of 100 practicing ophthalmologists who volunteered to participate from the ranks of participants of the eyeCONNECTIONS online commu- nity and volunteers around the U.S. Responses are anonymous in order to encourage candor. The first question was, "On the operating room table after cataract surgery, to seal the incision, do you normally use:" Choices and percent answers were: T he temporal clear cornea incision, pioneered by I. Howard Fine, MD, has become one of the most popular incision methods for cataract surgery due to its advan- tages of ease of creation, favorable approach to the lens without crowd- ing of instruments by the brow, and relative ease in sealing without a suture. But how do we ensure that the incision is secure, both on the table and during postoperative fol- low-up? This question was prompted by a case of my own. The case was an out-of-town patient undergoing cataract surgery and seen by her co-managing optometrist locally the next day. The optometrist called my technician the following day concerned about a wound leak, and the patient was sent right over. At exam, the main clear cornea incision and paracentesis appeared secure, the intraocular pressure was normal, and the anterior chamber normally Clear corneal incision security testing Suture 6% Glue 0% Hydrate interior of incision (sides, roof, or both) 61% Hydrate "Wong" supraincisional pocket 1 16% Other 7% Dry incision and press on eye to try to provoke aqueous leak 58% Drop of dilute fluorescein 0% Paint with dry fluorescein strip and press on eye to provoke Seidel+ test 11% If pressure fine, chamber deep, assume seal is adequate 27% Other 3% Digital, or with instrument such as a cannula, globe indentation 95% Confirm at least light perception vision 9% Tonometer (any type) 4% Yes 13% No 82% Mitch Gossman, MD One "other" response was intra- cameral triamcinolone, presumably to watch for particles streaming The total is greater than 100% due to multiple responses being allowed. The fourth question was, "At the POD #1 visit, do you routine- ly do a formal Seidel test with dry fluorescein painting of the incisions? Everyone does if there is low IOP, flat chamber, or self-evident leak with or without Fluress; this is for a normal POD #1 examination." Is it possible that ophthalmol- ogists have their heads in the sand and there are important intraop- erative or postoperative leaks that go undetected? Is it these that are destined to develop endophthal- mitis at a higher rate, perhaps even a majority of cases? Sam Masket, MD, clinical professor, University of California, Los Angeles, and in pri- vate practice, Advanced Vision Care, Los Angeles, thinks this is possible. According to Dr. Masket: "I continue to perform intra- operative Seidel tests on all in- cisions, including paracenteses after setting IOP at physiologic levels as measured tonomet- rically. I don't leave the table until they are dry by whatever necessary means, which is most toward a leaky incision in addition to use for suppressing postoperative inflammation. The third question was, "How do you check IOP at the end of the case when the patient is on the OR table?" Are you a fan of EyeWorld? Like us on Facebook at facebook.com/EyeWorldMagazine Find us on social media EyeWorld@EWNews Keep up on the latest in ophthalmology! Follow EyeWorld on Twitter at twitter.com/EWNews Pulse of ophthalmology: Survey of clinical practices and opinion

• Cover