Eyeworld

85 August 2016 EW MEETING REPORTER Dr. Biswas accused Dr. Chee of going through unnecessary acro- batics when she could have used a glued or scleral fixated IOL. "Professor Chee, one of the best surgeons in the world, is guilty of propagating impossible techniques to our very normal surgical skills," Dr. Biswas said. In the end, Dr. Chee was praised for her surgical skill by the judge and jury. Cesar Espiritu, MD, Manila, Philippines, presented on his decision to use an anterior capsule IOL for a patient with a severely damaged iris, thinking it wouldn't support an iris sutured IOL or iris clawed IOL. Dr. Espiritu received criticism for this choice by some in the jury, but in the end Dr. Luthra said that while it might not have been the best choice in this scenario, it doesn't mean it was wrong. Thus he was found not guilty. Ritika Sachdev, MD, New Delhi, India, presented on a case of phacomorphic glaucoma where she performed a limited dry pars plana vitrectomy to decompress the globe for cataract surgery. Dr. Biswas criti- cized Dr. Sachdev for making a sin- gle vitreous port, using no infusion, and not making a complete vitrec- tomy. In the end, Dr. Luthra said Dr. Sachdev chose the right approach. Finally, Sri Ganesh, MD, Ban- galore, India, was brought to the stand. His was a case of intraopera- tive iridodialysis in a routine phaco case. Calling it a "freak accident," nearly half of the iris came into the phaco port. Instead of panicking and removing the phaco tip, Dr. Ganesh used his viscocannula to gently remove the entangled iris. He proceeded to place iris hooks and finish the cataract surgery, before performing an iridodialysis. Dr. Ganesh was found not guilty and offered this defense: "The only surgeon who has no complication is one who does not operate." "What I want to demonstrate is, yes, some freak accidents can happen," Dr. Ganesh said. "What is important is to keep calm in that moment." EW incision, and did a nuclear expres- sion. After vitrectomy, Dr. Pangputh- ipong placed a scleral fixated IOL and the patient outcome in the end was good. So what went wrong? Dr. Pangputhipong hypothesized that his capsular tension ring size was too big and there was friction with his use of the injector. He also noted for the jury that at the time, Thai- land only had plain capsular tension rings. Capsule hooks were also not available. "A CTR was placed without capsular hooks in a truly subluxated lens. No capsular hook to support this subluxated lens. He went ahead straight with the injector … with a larger CTR than was required. This is absolutely the wrong way," Dr. Biswas, clad in a black court robe, said emphatically. Dr. Ramamurthy said her de- fendant's message in this case was that he realized his mistake, pulled out the capsular tension ring, and removed the nucleus without the lens sinking. "The final outcome is what has to be seen," she said, later describing the video as a teaching moment for the audience. Unfortunately, the supreme judge agreed with the prosecu- tion, going against the majority of the jury, which had criticized Dr. Pangputhipong's decision to use a capsular tension ring but still mostly voted him as not guilty. Next up, Chee Soon Phaik, MD, Singapore, took the stand. Her case was that of a woman with a decentered lens, which she could hardly see at the time of surgery. Dr. Chee expanded the pupil with iris hooks and used microforceps to grasp the capsule, which she said was fibrotic. Taking care to not grasp any vitreous, she removed the haptics from the capsular bag and brought the lens forward to fixate it. Keeping hold of the lens, she made another paracentesis and used 10.0 prolene sutures to hook around the lens on each side, only tightening the knot on either side after she was sure the lens was perfectly centered. (SIA) in all participants (n=68) was 0.20±0.17@74; the posterior SIA in ATR astigmatism of posterior cornea (n=61) was 0.19±0.16@75. He concluded that "2.2-mm temporal limbo-corneal incision cat- aract surgery may have no clinically significant impact on posterior cor- neal surface especially in ATR astig- matism of the posterior cornea." "Court-martialed" surgeons present their cases to judge and jury Surgeons "charged with incompe- tence" were sent to answer for their cases at the APACRS "Court Martial in Ophthalmic Surgery" symposium. Bringing cases before supreme judge Gaurav Luthra, MD, Dehra- dun, India, and a panel of six hon- orable jury members was upright public prosecutor Partha Biswas, MD, Kolkata, India. Chitra Ramamurthy, MD, Coimbatore, India, provided defense counsel. The first defendant brought before the judge and jury, Pannet Pangputhipong, MD, Bangkok, Thailand, described a subluxated lens case conducted in 2008 where he tried to implant a capsular ten- sion ring. When doing so, he found the lens moved. He tried to apply counter traction, but the whole lens moved almost 360 degrees. At this point, he stopped sur- gery, removed the ring, extended the minutes—and a cycloplegic dilator to examine the vitreous and retina. His acute management also includes aggressive, broad spectrum antibiot- ics every 15 minutes. If uncertain, Dr. Espiritu recom- mended treating the worse condi- tion. Should the surgeon determine the case is one of endophthalmitis, the patient should be admitted, specimens for stain, culture, and sensitivity testing collected, paren- teral and intraocular antibiotics ini- tiated, and vitrectomy and intraocu- lar lens explantation performed. To minimize risk of both TASS and endophthalmitis, Dr. Espiritu said that practices should institu- tionalize recommended preventive measures, citing three critical steps in reprocessing—cleaning and decontamination, sterilization, and careful storage or return to the sterile field. Also at the symposium, Chul Young Choi, MD, Seoul, South Korea, presented the results of a prospective study utilizing devel- opments in topography to evaluate postoperative changes in posterior curvature. Dr. Choi found that the dif- ference between preoperative and 6-months postop keratometric data on the posterior surface was not statistically significant. The poste- rior surgically induced astigmatism View videos from APACRS 2016: EWrePlay.org Sri Ganesh, MD, describes techniques for managing presbyopia with laser vision correction.

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