Eyeworld

79 EW MEETING REPORTER July 2016 meeting in São Paulo Dr. Wilson added that he typically does not do a contact lens trial for lower levels of monovision. These are not a good predictor of whether the patient will accommo- date to and enjoy monovision, he said. Many patients who do not like partial monovision in contact lenses find that they do when the correc- tion is permanently in the eyes. Typically, the approach is the dominant eye for distance, Dr. Wilson said. If the patient has no clear ocular preference, he or she commonly can do well with either eye for distance. If the patient is already wearing it in contact lenses, do not change, he said. So which method should be used? LASIK, LASEK, and PRK appear to be equally effective. Dr. Wilson recommended not exceeding 4 D of total hyperopic correction or vision quality may be reduced. LTK and conductive keratoplasty are options, he added, but maximal correction and stability over time are poor. Dr. Wilson's strategy is to en- courage all patients over 40 who do not have demanding distance visual tasks to consider partial monovision. There is a low enhancement rate at 3 months for those who are not sat- isfied, he said. Patients can consider enhancing to more minus when the current level of monovision is no longer adequate. Femtosecond laser Alessandro Mularoni, MD, Bolo- gna, Italy, presented "Femtosecond Laser Implantation for Intracorneal Rings: Strategies in Basic and Chal- lenging Cases." He highlighted 2 kinds of tech- nology for implanting intracorneal rings, which include a mechanical method and the femtosecond laser. The femtosecond laser is com- fortable for the patient and for the surgeon, he said. In the literature, there are a few comparisons between the 2 techniques. In several reports, there seemed to be little difference between visual acuity and refraction, but there were some complications shown in the mechanical group. Dr. Mularoni offered a 5-step protocol when implanting intra- corneal rings. The first step is to choose the ring shape. In this step, thickness of the ICL and optical size should be considered. When you have to prepare the canal, you have to determine the outer and inner diameter, he said. The second step is to program the center of your treatment. In general, the best solution is to center the treatment on the center of the pupil, especially to avoid halos. The third step, Dr. Mularoni said, which is very important, is to center the pupil in the pachymet- ric map. You need a very complete pachymetry map, he said, not just a point. The preparation of treatment parameters in the laser is the fourth step. And finally, he said the fifth step is the surgery, including laser treatment and ring implantation. Dr. Mularoni said that the fem- tosecond laser can also be used in challenging cases. Managing posterior capsule tear and vitreous loss A session at the meeting was devot- ed to the topic of posterior capsule rupture and IOL implantation with- out capsular support. Marcio Nehemy, MD, Belo Horizonte, Brazil, presented on how to manage posterior capsule (PC) tear, speaking from the opinion of a retinal surgeon. This is a rare com- plication but potentially very severe, he said. The occurrence of PC tear can change everything. Posterior capsule tear can occur with a number of conditions, including a hard nucleus, pseudo- exfoliation, previous vitrectomy, intumescent cataract, posterior polar cataract, and ocular hypertension, or because of the surgeon learning curve. However, it can also happen in the absence of these and even for experienced surgeons, Dr. Nehemy said. PC tear may be worsened with vitreous loss, vitreous in the wound, vitreous in the anterior chamber, re- tained lens material, and dislocated IOL, he added. Posterior capsule tear is a com- plication in surgery, Dr. Nehemy said. The first step is to admit there is a problem. In surgery, 1 mistake has consequences, but 2 consecutive mistakes can make the problem even more serious, he said. It's important to stop and take a step back if you see this problem occurring. Brian Little, MD, London, spoke about vitreous loss prevention and modern management. Although vitreous loss only occurs now in 1–2% of cases, it can still be a sig- nificant complication. Vitreous loss can cause a number of problems, including increased risk of retinal detachment. The relative risk of ret- inal detachment after vitreous loss in the first 3 months is 40 times the standard ratio, Dr. Little said. So how can we improve the outcomes? Dr. Little said this comes with the understanding of what vit- reous is, how to handle it properly, and how to remove it safely. Don't pull on the vitreous base when doing an anterior vitrecto- my, he recommended. Because we don't see it, we don't think about it, he said, and often the vitreous is subjected to greater traction than it can stand. Dr. Little offered a number of tips for managing vitreous loss, including don't panic, don't deny it, don't pull it, visualize it, remove it, and follow it up. He said it's very important not to deny it. "We're all guilty of pretending it hasn't happened," he said. But if you continue to phaco after the capsule is gone, even in 5 seconds you can do damage to the retina. As soon as you see it happen, stop, he said. In conclusion, Dr. Little said there are several main points to re- member about vitreous loss. This is a serious problem, he said, so accept it, be calm, and decide on a strategy. He also said to respect the vitreous base. Cut, don't pull on, the vitre- ous, and remove the vitreous metic- ulously, Dr. Little added. Finally, he said to avoid collapsing the eye. Editors' note: Dr. Nehemy's presenta- tion was reported on from a translation from Portuguese to English. Treatment options in posterior capsule rupture Also during the session on posterior capsule rupture, specific surgical op- tions in these cases were discussed. Boris Malyugin, MD, Moscow, discussed surgical options for intra- capsular IOL fixation in a patient with PC rupture. There are a number of surgical options when you have PC rent, he said. These can include IOL options, like anterior chamber angle fixation, iris fixation, and PCIOL. Some general recommendations he offered were to keep the anterior chamber filled, remove the residual nuclear material, perform anterior or pars plana vitrectomy, and make a decision regarding the IOL. It's important to preserve the capsular remnants for IOL fixation, he said. Dr. Malyugin also shared several cases and videos where PC rent had occurred. In summary, he said that in cases of posterior capsule rent, don't panic. Know your backup options, and create a surgical plan and follow it. You can also get help if necessary, Dr. Malyugin said. continued on page 80

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