Eyeworld

95 February 2016 EW MEETING REPORTER asked to weigh in on what they would do in different situations. The first case, presented by Dr. Chang, looked at a misaligned toric IOL. Audience members were asked what they would do with a toric misaligned by 15 degrees. More than half (57%) of those voting chose to rotate the lens in the OR without a capsular tension ring (CTR). Dr. Chang's case was a 73-year- old at 4 weeks postop who had a T5, high power toric IOL with a target axis of 175. The other eye already had a toric. Since the capsule had begun to tear, the lens was not rotated to the correct position, so it was only at 110 instead of its target 175. Even with the many issues involved with this case, the majority of audience members (59%) still said that they would try to reposition this toric IOL instead of exchanging it with a different one. If you rotate the lens, don't do so with traction in the vitreous, Dr. Ho said, because this could lead to tears and other complications. An anterior vitrectomy then IOL removal or reposition was the initial choice for 38% of attendees. A second panel consisting of Preeya Gupta, MD, Durham, N.C., John Berdahl, MD, Sioux Falls, S.D., Uday Devgan, MD, Los Angeles, Randall Olson, MD, Salt Lake City, and John Vukich, MD, Madison, Wis., weighed in on several other cases. The first case they looked at was a traumatic cataract and the second was a rock hard lens with a crowded AC. Dr. Chang's rock hard cataract patient was a 67-year-old referred patient. The pupil was stuck down and the eye was atrophic in the stroma. Additionally, the anterior chamber was extremely shallow. There was no iris separation, Dr. Chang said, and the patient was 20/40 in the good eye. Right away, Dr. Chang had a lot of concerns in the case. You have to consider what's going to happen to the iris, how to preserve the cornea, and how to put the phaco tip in the eye. W. Barry Lee, MD, Atlanta, highlighted pearls for dealing with white cataracts. This type of cata- racts may be particularly challenging because they pose difficulty with anterior capsule view, often are associated with small pupils, and zonular laxity is more common, Dr. Lee said. Surgeons may want to use anterior capsule staining techniques, like trypan blue or indocyanine green. "Be prepared for the unex- pected," he said. Additionally, Dr. Lee recommended having adjunct devices readily available, like capsule staining dye, capsular tension rings, and pupil expansion devices. He also said to have a back-up IOL ready for the sulcus. Dr. Lee offered intraoperative tips for dealing with white cata- racts. Consider femtosecond as an adjunct, he said. Use trypan blue, use a cohesive viscoelastic with high molecular weight for the rhexis, consider decompression of the lens prior to starting the rhexis to lower intralenticular pressure, use copious dispersive viscoelastic to protect the cornea during phaco, and use chopping techniques when possible, he said. Since every cataract surgery is different, it's important to be pre- pared for special situations that can increase the complexity of the pro- cedures. Mastering available adjunct devices can help make difficult cases more routine, Dr. Lee said. Editors' note: Dr. Talley-Rostov has financial interests with Allergan and Bausch + Lomb. Dr. Lee has financial interests with Shire (Lexington, Mass.) and Bausch + Lomb. Cataract surgery complications Surgery complications were dis- cussed via video case presentations involving cataract and IOL compli- cations. David F. Chang, MD, Los Altos, Calif., moderated the session, with Elizabeth Yeu, MD, Norfolk, Va., Allen Ho, MD, Philadelphia, Audrey Talley-Rostov, MD, Seattle, Kevin Miller, MD, Los Angeles, and William Trattler, MD, Miami, serving as panelists. Attendees were continued on page 96

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