Eyeworld

EW FEATURE 82 Complex cataract cases October 2015 • When available, a femtosecond laser can help with capsulotomy creation in a white or brown cataract. If the laser is not available, staining with trypan blue can assist with visualization. • Surgeons must use caution to avoid the Argentinian flag sign in white cataracts. • An ideal OVD will stay in place during surgery and make the procedure safer. • Preop testing can help detect other problems in these eyes that may be hard to visualize. Medications such as steroids and NSAIDs are best given for a longer time period than in other patients. by Vanessa Caceres EyeWorld Contributing Writer Cullen Eye Institute, Baylor College of Medicine, Houston. To help avoid the Argentinian flag sign, Dr. Weikert recommends piercing with a 27-gauge needle and quickly aspirating lens material. "You may need to aspirate with a cannula to get more out. If there's a significant amount of liquefied cortex, it can be a back and forth process," he said. Surgeons can also use the Little maneuver if the capsu- lorhexis starts to go out toward the and postop diagnostics and manage- ment will go a long way toward a better surgery. Here are some ways to better manage a dense lens or an intumes- cent or brunescent cataract. Capsulorhexis tips One reason to carefully create your capsulorhexis in a white cataract is because the capsule is more friable and under pressure due to capsular distension syndrome, said Kendall E. Donaldson, MD, asso- ciate professor of ophthalmology, Bascom Palmer Eye Institute, Miami. In a dense brunescent cataract, visualization is often difficult, Dr. Donaldson said. This is why Dr. Donaldson prefers use of femtosecond laser technology in both circumstances. "Increased speed of capsulotomy creation increases the safety of the capsulotomy and prevents the po- tential extension of an anterior cap- sular tear, known as the Argentinian flag sign," she said. "For the dense brunescent cataract, the femtosec- ond laser eliminates this challenge by creating a perfectly centered, round capsulotomy, which then facilitates the rest of surgery." Although Stephen S. Lane, MD, medical director, Associated Eye Care, and adjunct clinical professor, University of Minnesota, Minneapo- lis, also favors femtosecond laser use for a capsulorhexis in these cases, he advises capsule staining with trypan blue if this is not possible, especially with a white lens. "I think it's become the standard of care to reduce complications. It allows you to perform a much more predictable and secure capsulorhexis," he said. Surgeons need to remember that the capsule in these lenses tends to be more brittle, and they should go more slowly, said Mitchell P. Weikert, MD, associate professor and residency program director, Managing "catarocks": Better surgery on dense lenses, intumescent cataracts Monthly Pulse October 2015 T he topic of this Monthly Pulse survey was "Complex cataract cases." We asked what physicians would do when faced with lack of capsular support, and more than half of the respondents to the survey said that they would insert an ACIOL. For cataract patients with short eyes, the majority of respondents to the survey chose "All of the above": use a super cohesive viscoelastic to maintain space, use a dispersive viscoelastic to protect the cornea, and create a longer incision for stability. When dealing with ocular surface disease and cataracts, a large majority would optimize the corneal surface prior to biometry test. Finally, we asked what physicians would do when they suspect a patient has AMD with cataract; the most popu- lar answer was "Perform a macular OCT," followed closely by "Counsel the patient on limitations." Surgical pearls for increased safety, smoother procedures M anaging a complex cataract case may try physicians' patience, but there are some ways to make surgery and postop management of these cases go more smoothly. Careful consideration of the capsulorhexis, ophthalmic viscosur- gical device (OVD) use, femtosecond laser use when available, and pre- AT A GLANCE Hypermature white cataract. According to Dr. Donaldson, this patient would benefit from femtosecond laser pre-fragmentation. Source: Kendall E. Donaldson, MD

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