EW NEWS & OPINION
June 2016
23
performed to get through the thick
and dense posterior plate. During
sculpting, care was taken not to
torque the phaco needle against the
roof or sides of the incision, which
would increase risk of a wound burn.
Pieces were then torn off each lens
Figure 1: Slit lamp view of the cataract
Figure 2: Slit lamp image of patient's eye 1 month after cataract surgery
Source: Steven Safran, MD
half for phacoemulsification using a
hybrid horizontal/vertical chopping/
shearing technique using a Sinskey
hook as a second instrument and
relatively high suction power to gain
purchase on this extremely leathery
nucleus. I found that lens pieces did
not readily separate with chopping
and that I had to tear the pieces off
like I was dealing with rawhide. Fre-
quent refills of the anterior chamber
with dispersive viscoelastic were
performed throughout the case to
protect the cornea endothelium. At
the conclusion of phaco the incision
showed no evidence of heat-related
contraction and thus no suture was
required. Although the cornea had
2–3+ edema on day 1, by 1 week
there were only trace Descemet's
folds and vision had improved to
20/40 uncorrected. By 1 month the
cornea was clear, and the patient
was very satisfied with uncorrected
20/25 vision.
Based on the responses from
other surgeons it seems clear that
ECCE in such a case is a reasonable
option and one that even some
of the most accomplished phaco
surgeons would consider as their
first-line approach. It does, however,
carry an increased risk of choroidal
hemorrhage, induced astigmatism,
and ocular surface problems. It
seems clear that there is little role
for femtosecond laser-assisted nu-
cleus disassembly in such a case as
the laser cannot cut what it can-
not visualize. In addition, a recent
article has suggested that there may
be increased risk of "suboptimal
capsulotomy outcomes" when the
femtosecond laser is used to create
a capsulotomy in mature cataracts.
1
Manual phacoemulsification can
also be successfully performed but
with risk to the cornea endothelium
and other ocular structures; that
needs to be carefully avoided and
with appropriate measures usually
can be. Important considerations
are the use of copious dispersive
viscoelastic throughout the case to
protect the cornea and a fresh sharp
phaco needle to avoid wound burns
and zonular damage. EW
Reference
1. Asena BS, et al. Comparison of the efficacy
and safety of femtosecond laser capsulotomy
between mature and non-mature cataracts.
Lasers Surg Med. 2016 April 22. [Epub ahead
of print]
Editors' note: The physicians have
no financial interests related to their
comments.
Contact information
Gorovoy: blehet@gorovoyeye.com
Hester: hesterchristianc@gmail.com
Masket: sammasket@aol.com
Oren: rlodad@bellsouth.net
Pyfer: mpyfer@verizon.net
Safran: safran12@comcast.net
Watch a video of this
case now at EyeWorld
Clinical rePlay
clinical.ewreplay.org
