Eyeworld

EW NEWS & OPINION 22 June 2016 Anterior segment grand rounds (ASGR) by Steven Safran, MD Christian Hester, MD, Little Rock, Arkansas, said, "If there was no evidence of phacodonesis, I would proceed with phaco under a peribulbar block using my stan- dard clear corneal incision on the steep axis, staining the capsule with trypan blue, and carefully perform- ing a capsulorhexis that would be adequate for optic capture if needed. After filling the anterior chamber with a dispersive OVD (which I would liberally use throughout the case), I would attempt to make a central groove in the nucleus at least as deep as the width of 1 phaco tip. I then would proceed with vertical chop using either a Chang vertical chopper or Rosen vertical chopper, making my first chop in the central groove. The critical step of this ap- proach is that you get a good central full thickness crack through the lens. Once this has been accomplished, you are almost home free and just need to be careful while disassem- bling the rest of the lens. I generally take risk-adverse approaches to high- risk cases. Therefore, if I detected zonular instability, I would proceed with a small incision extracapsular cataract extraction." What was done Phacoemulsification was performed in this case under topical anesthesia, with placement of a single-piece acrylic lens (ZCB00, Abbott Medical Optics, Abbott Park, Illinois). An LRI was done at the time of surgery to reduce astigmatism. IOLMaster (Carl Zeiss Meditec, Jena, Germany) mea- surements were not possible so axial length was determined by ultra- sound. Trypan blue was used to stain the anterior capsule, and a fresh sharp phaco needle was used to improve cutting efficiency. I chose the purple tip needle through a 2.2 mm incision using the Stellaris pha- co machine (Bausch + Lomb) with phaco power set at 100% during sculpting on continuous power de- livery (no pulse modulation). Power delivery was controlled by light pres- sure or feathering of the foot pedal, so most of that power was on tap rather than being applied at any giv- en time. A deep, wide central groove was obtained with "reverse slope sculpting" of the lens, and a bottom up crack through the nucleus was ral large (internal opening 9.5 mm) frown-shaped sclerocorneal inci- sion. A large anterior capsulotomy is necessary, but visualization will be poor as no red reflex is visible; femtosecond laser capsulotomy can be attempted. If a large capsu- lorhexis isn't obtainable, I would perform a 'can-opener' capsulotomy with a cystotome, viscodissect the nucleus, and remove it with a lens loop. The incision can be closed and the cortex removed in a bimanual fashion via paracentesis. I would opt for a STAAR [Monrovia, California] AQ2010V IOL in the sulcus or cap- sule bag varying with the condition of capsule remnant. View my YouTube account (youtu.be/ 9BpRbp9s2j8) for a video of similar case management of a Morgagnian cataract using a femtosecond laser for the anterior capsulotomy." Brad Oren, MD, Boynton Beach, Florida, commented, "Should the patient desire rehabilitation of vision in this eye, my choice would be to undertake phacoemulsification cataract extraction with a horizon- tal chop method. I find that with modern phaco and fluidics, these lenses can often be chopped and removed without corneal endo- thelial or wound damage. I would undertake a paracentesis and reform the anterior chamber with air (under the assumption that there is no useful red reflex to guide a CCC) and place trypan blue under air. Next, a dispersive viscoelastic to protect the corneal endothelium is used to reform the anterior chamber. In consideration of a need to convert to MSICS, I would make a temporal 2.7-mm scleral incision. A large CCC (just under 6 mm) will allow for de- livery of the crystalline lens should phacoemulsification be unsuccessful. I would hydrodissect this lens very gingerly considering this is a black lens sitting above a 95-year-old pos- terior capsule. Chopping of the crys- talline lens is then undertaken with very small 'pieces of pie' removed at a time. If I became concerned about the patient's endothelium during the case, I would not hesitate to con- vert to MSICS. I'd enlarge the scleral incision, replace viscoelastic lost during attempted phacoemulsifica- tion, and deliver the crystalline lens with lens loop or irrigating vectus if available." Patient with history of complicated cataract surgery has a black cataract. Should the patient have surgery? If so, what method? I asked a group of accomplished cataract surgeons if they would recommend cataract surgery here. If so, with what method: phacoemulsification, ECCE, or femtosecond laser-assisted cataract surgery? Here are their comments. Mark Gorovoy, MD, Fort My- ers, Florida, commented, "My choice is no surgery if functioning well, as opposed to a planned ECCE. I can phaco very brunescent cases but not black ones safely. ECCE was my standard of care for many years in the 1980s with great results. I rarely have to do these cases but still sit temporal and make an 8–10 mm limbal incision after a very large cap- sulotomy and manually express out the nucleus with external compres- Black cat means bad luck? Not always T his is a healthy and active 95-year- old woman referred in for cataract surgery in her left eye. She has a history of previous complicated cataract surgery in the right eye with placement of an ACIOL and subsequent development of glaucoma. She sees 20/30 in that eye and has an IOP of 21 on topical medication. In the left eye she has a black cataract with HM vision and an IOP of 18 on no medi- cation. Her endothelial cell count is in the 2300 range OS, her pupil dilates well, and she has no obvious evidence of zonular weakness. Although the posterior segment cannot be visualized or imaged at all, she has no relative afferent pupillary defect (RAPD). She has 1 D of against-the-rule corneal astigmatism. She is interested in improving her vision in this eye and would be willing to have cataract surgery if I think that there is a good chance of improving her vision without too much risk. Steven Safran, MD, ASGR editor sion on the opposite limbus as well as at the wound site." Mark Pyfer, MD, Jenkintown, Pennsylvania, said, "Phaco surgery is not out of the question. However, manual small incision cataract sur- gery (MSICS), as performed all over the world successfully for hyperma- ture cataracts, is an excellent option, and may offer the fastest visual rehabilitation. "I would attempt phacoemul- sification with a temporal limbal corneal incision, using trypan blue to stain the capsule, with copious dispersive viscoelastic reapplied. Modern phaco machines with tor- sional and hyperpulse modulation are gentler to the endothelium, since this case will likely require 50–80 seconds of equivalent ultrasound time. I have found the new bal- anced tip with the Centurion phaco machine [Alcon, Fort Worth, Texas] to perform very well on extreme- ly dense lenses. Mackool's central sculpting technique, followed by chopping the peripheral bowl, should help to fragment the leath- ery posterior plate frequently found in very dense cataracts. If unable to sculpt the lens without risking a wound burn, I would then convert to MSICS. "I perform femto laser-assisted surgery frequently, but do not think it would be helpful in this case. I have found that due to limited optical penetration, laser fragmenta- tion of a lens this dense is minimal despite application of significant energy." Samuel Masket, MD, Los Ange- les, noted, "Cataract surgery is indi- cated if the patient desires and needs improved vision, understands the risks, benefits, and alternatives to surgery, and has a reasonably good prognosis and no medical contrain- dications. Age is not a diagnosis. My experience suggests that the Alcon balanced tip and the Bausch + Lomb [Bridgewater, New Jersey] purple tip are capable of cutting very dense cat- aracts and might be able to success- fully tackle this truly black cataract. On the other hand, femtosecond la- ser platforms cannot image through this cataract and are therefore not useful in this case other than for the anterior capsulotomy. "That said, my preference is to perform manual ECCE via a tempo-

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