Eyeworld

Reporting from the 29th APACRS annual meeting, July 27–30, 2016, Nusa Dua, Bali Sponsored by EW MEETING REPORTER 84 August 2016 He shared his dilating drops pro- tocol that he said should be strong enough for most pupils. Although this is not a common problem, Dr. Ang said surgeons need to be prepared. Cataract conundrums When you see a patient the day after surgery—"And I do encourage you to see your patient a day after sur- gery," Cesar Espiritu, MD, Manila, Philippines, said—with a cloudy cornea and poor vision, your heart, Dr. Espiritu said, "really drops." In patients like these, he said, you are dealing with one of two of the most depressing potential com- plications of cataract surgery: toxic anterior segment syndrome (TASS) or infectious endophthalmitis. Dr. Espiritu discussed these conditions at the "Cataract Conun- drums" symposium. Infection is, of course, right up front, the more frightening prospect. Still, he said, "TASS isn't a thing to be brushed aside." TASS, he said, can induce per- manent corneal endothelial damage. It can also induce glaucoma due to permanent damage to the trabecular meshwork. "Depending on the type and du- ration of the toxic insult, the visual outcome can range from 20/20 to no light perception," he said. "Patients may require further intraocular procedures, such as penetrating kera- toplasty and/or glaucoma filtering procedure surgery to regain visual function." The surgeon needs to recog- nize and manage the problem early enough to avoid these consequenc- es, Dr. Espiritu said, and the immedi- ate task is to differentiate inflamma- tion from infection. There are a number of variable differences between TASS and en- dophthalmitis, but the surest signs are vitritis—rarely present in TASS, always present in endophthalmitis— and response to steroids—dramatic improvement in TASS, equivocal response in endophthalmitis. Dr. Espiritu thus recommends beginning with a steroid chal- lenge—prednisolone acetate 1% or dexamethasone eye drops every 10 Viraj Vasavada, MD, Ahmed- abad, India, presented on optimizing cataract surgery in post-refractive surgery eyes. Any refractive surgery has altered the corneal profile, she said, so there's a change in asphe- ricity and aberrations. This would affect IOL selection, and could pose potential postoperative issues. She also offered several pearls for IOL selection, including the need to counsel about both residual refractive error and the possibility of postoperative glares and halos. She also said to avoid multifocal IOLs in these patients. In his presentation, Johan Hutauruk, MD, Jakarta, Indonesia, shared several habits in highly effec- tive biometry. First, he said to avoid applanation and use the immersion. He also suggested not using a default A-constant for optical biometry. For premium lenses, Dr. Hutauruk said to use a manual keratometer. He said to be sure not to use an obsolete formula, like the SRK I or II. Always measure both eyes, and remeasure both eyes in special conditions, he said. His last tip was for a personal- ized A-constant. Robert Ang, MD, Manila, Philippines, highlighted the topic of small pupils in his presentation. Management of small pupils starts with recognizing the problem, he said. Dilating the pupil during screening/checkup prior to surgery is important, he said. This includes checking the retina, measuring po- tential visual acuity, and measuring the size of the dilated pupil. Planning for surgery is also affected with small pupils, Dr. Ang said, because if the patient wants the femtosecond laser, this could be impacted. If the pupil doesn't dilate, you cannot proceed, he said, so you may have to tell the patient that the femtosecond laser is not an option. You also have to prepare your instru- ments and devices, he said, as well as manage expectations. Some causes of a small, poorly dilating pupil include diabetes, pseudoexfoliation, synechiae, or unidentifiable reasons. Dr. Ang said that with these pupils, you have increased the degree of difficulty of the surgery. IOL axial position, and no signif- icant difference in IOL tilt. The eccentric group was slightly more likely to have a higher tendency for IOL decentration. As such, Dr. Findl said he thinks the "rhexis effect is weak." "Does femtosecond laser-assist- ed cataract surgery result in more predictable IOL position? My answer at this point is no," Dr. Findl said. Other panelists agreed with this conclusion. What about preexisting phakic IOLs and their impact on cataract surgery outcomes? Jaime Aramberri, MD, San Sebas- tian, Spain, presented on research that evaluated how phakic IOLs could affect biometry for IOL calcu- lations in cataract surgery. Different materials—acrylic or silicone, for ex- ample—can affect the wavelengths for ultrasound or optical biometry, which can thus affect the axial length calculations. For example, he found that if ultrasound speed settings are not adjusted for phakic IOL materi- als that are considered faster, like acrylic, the axial length is under- estimated and IOL power is over- estimated, thus creating a myopic error after cataract surgery. A slower material, such as silicone, without adjusted ultrasound speeds results in an overestimated axial length and underestimated IOL power, creating a hyperopic error. Phakic IOL ma- terial had a similar effect on optical biometry as well. Overall, Dr. Aramberri found the myopic lens error created by faster phakic IOL materials was negligible, but slower phakic IOL materials creating a hyperopic lens error is significant and should be corrected by adding a correcting factor. Phaco technologies and techniques The "Phaco Technologies and Techniques" symposium highlight- ed both techniques for removing cataracts and the technologies most relevant for this. The session also included a special lecture by Sanduk Ruit, MD, Kathmandu, Nepal, on "Logistics of Phaco for High Volume Community Cataract Surgery."

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