Eyeworld

165 EW MEETING REPORTER both ports, Dr. Koplin's presentation focused on relatively recent research that found a fulcrum effect in the phaco handpiece where one fluid port becomes temporarily blocked by the needle as it moves laterally. This causes fluid from the unblocked side to come out at a greater veloci- ty, which he said can result in floppy iris and/or lens material being driven through the zonules into the vitreous when caught in this infu- sion wave. Dr. Koplin said that future work will determine how to fix this "serious problem," but for now he said "the more centric you operate with your phaco needle, the qui- eter the eye is going to be. For the moment, that's the best you can do." He added that they are working on a solution to this problem, which includes a sleeve for the needle that maintains symmetrical infusion. Brandon Ayres, MD, Philadel- phia, spoke to attendees about ways to manage a hypermature cataract. He broke this down, talking about 2 types of lenses: the white lens and the brown lens. With the white lens, or the intumescent cataract, the big issue is making the capsulorhexis and making it complete, he said. Meanwhile, the main issue with a brown lens is getting the posterior plate split in order to remove the lens. comes out at once; the dispersive type is like elbow macaroni and needs to be removed piece by piece. Cohesive viscoelastic is used to create or maintain space to inflate the capsular bag. Dispersive, on the other hand, is used to coat surfaces of intraocular structures for protec- tion. Two other types are (1) visco- adaptive materials, such as Healon5 (Abbott Medical Optics), which has a viscosity that changes based on flow rate, and (2) systems that have both dispersive and cohesive vis- coelastic sold in the same package, such as DuoVisc (Alcon). Viscoelastics can be especially useful in cases of floppy iris syn- drome, where Dr. Park said she would use a highly cohesive variety to maintain that space. A dispersive viscoelastic, in addition to protect- ing corneal endothelium, could help compartmentalize the eye in the event of posterior capsular rupture. Dr. Park said Healon5 would be useful in pediatric cases where the anterior capsule is rubbery. Another detail, for which research is just starting to emerge, is what Richard Koplin, MD, New York, called "a paradigm shift" in the understanding of "phaco fluid- ics." While the ideal infusion of fluid from the phaco tip is a centered in- fusion with equal fluid flowing from Editors' note: Dr. Ayres has financial interests with Alcon, Allergan, Bausch + Lomb, BioTissue (Doral, Florida), and Shire. Dr. Pineda has financial interests with Amgen (Thousand Oaks, California), Beaver-Visitec Inter- national (Waltham, Massachusetts), and Sanofi Genzyme (Cambridge, Massachusetts). Managing complex cataracts Viscoelastic, compared to other tools in cataract surgery, is often an afterthought. Understanding the different types of viscoelastic, their properties, and specific uses can aid in successful outcomes. "In the first few years as you're honing your surgical skills and shooting for excellent outcomes and going for that patient to come back postop day 1 [at] 20/20, it's in all the details. All the choices and the little decisions that you make can make a real difference," said Lisa Park, MD, New York. "Viscoelastic is one of them." Dr. Park gave an overview of the 2 basic types of viscoelastics: cohesive and dispersive. While cohesive viscoelastic has a high molecular weight and tends to adhere together, dispersive viscoelastic has a shorter molecular length. Dr. Park compared them to pasta. The cohesive variety is like intertwined spaghetti noodles, and when it is removed, it usually all surgeries will require an excimer laser enhancement. So who is a good candidate for laser vision correction after cataract surgery? Those with low to mod- erate refractive errors whose vision clearly improves with a refraction that affects visual performance are candidates, he said, as well as those who may not be candidates for an IOL exchange or a piggyback IOL, and patients without major iris dam- age. "Avoid laser vision correction in those multifocal patients where the vision is waxy or filmy," Dr. Pineda said. "Evaluation of the postop IOL patient is going to involve under- standing the patient's complaint and his or her particular needs," he said. Knowing exactly what the patient is complaining about is very import- ant, he said. You need to know if the patient is having blurry vision and if the problems are constant or fluc- tuating. Doing a clinical exam and repeating tests is also important in managing these patients. Dr. Pineda recommended reviewing possible options with the patient and creat- ing a clear plan for each individual. "These are patients who focus on the positives before the surgery but tend to focus on the negatives after the surgery," he said. "They want to know what's going on." April 2016 continued on page 166 View videos from YES ACT 2016: EWrePlay.org Christopher Starr, MD, discusses new devices for the management of meibomian gland dysfunction. View videos from YES ACT 2016: EWrePlay.org Himani Goyal, MD, discusses special considerations for teaching residents to perform femtosecond cataract surgery.

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