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EW CATARACT 50 September 2016 by Ellen Stodola EyeWorld Senior Staff Writer Remember to add dispersive viscoelastic, Dr. Donaldson said. She also recommended scheduling these cases at the end of the day so you're not rushed. Additionally, stopping to add OVD is key. The surgeons discussed other chopping techniques, including the vertical and horizontal chop tech- niques. Dr. Donaldson spoke about fragment management, saying you can chop them into small segments and apply high levels of vacuum and keep it close to the iris plane and out of the anterior chamber as much as possible. With a dense lens, the like- lihood of damaging the capsule increases as the case proceeds, Dr. Snyder said. There are many "cap- sule protector" options. "I will often inject the intraocular lens into the bag underneath the remaining frag- ments when the majority of the nu- cleus has been removed, finish the phaco and aspirate the cortex with the IOL in place. You don't have to do every step in the same order for every case," he said. EW Editors' note: Dr. Foster has finan- cial interests with Alcon (Fort Worth, Texas), Ivantis (Irvine, California), Alphaeon (Irvine, California), Bausch + Lomb (Bridgewater, New Jersey), and AcuFocus (Irvine, California). Dr. Donaldson has financial interests with Abbott Medical Optics (Abbott Park, Illinois), Alcon, Allergan (Dublin), BioTissue (Doral, Florida), and TearLab (San Diego). Dr. Solomon has financial interests with Abbott Medical Optics, Carl Zeiss Meditec (Jena, Germany), Clarity Medical Systems (Pleasanton, California), TrueVision (Santa Barbara, California), LENSAR (Orlando, Flori- da), i-Optics (The Hague, Netherlands), Nidek (Fremont, California), and Alcon. Dr. Snyder has financial interested with Xigen (Epalinges, Switzerland), Envisia (Durham, North Carolina), Bausch + Lomb, Haag-Streit USA (Mason, Ohio), HumanOptics (Erlangen, Germany), and Reata Pharmaceuticals (Irving, Texas). Contact information Donaldson: kdonaldson@med.miami.edu Foster: gjlfos@aol.com Snyder: msnyder@cincinnatieye.com Solomon: jdsolomon@hotmail.com clear manipulation. Capsular hooks give support so physicians have extra confidence in being able to phaco more normally in these cases, Dr. Donaldson said. The bag can inhibit the ad- vancement of the ring, Dr. Snyder said. Using either a capsular hook or sliding one of the Ahmed seg- ments into an area of loose zonules are quick ways to stabilize with no impact on further progression of cataract surgery, he said. Dr. Solomon also recommended using OVD liberally because main- taining the anterior chamber and endocapsular space is important. A third audience response question asked about techniques for dismantling a rock hard nucleus, with 36% of respondents choosing divide and conquer. With these cases, we should do what we feel comfortable with, Dr. Donaldson said. Chopping can be a benefit. Dr. Donaldson likes to make a short groove because it gives her more traction to separate the groove early. When doing nuclear disassem- bly, there are certain challenges to consider compared to a routine case. Dr. Solomon said that mini- mizing ultrasound energy becomes a challenge. Space is a commodity, and he recommended creating space and distance between the corneal endothelium. Don't create a groove or trench in a standard case, but do in a rock hard one, he said. Dr. Donaldson commented on how she would handle a capsulor- hexis in these challenging cases. She recommended using trypan blue with dense lenses. Visualization is poor, so any tool to make this easier is helpful. Dr. Donaldson said to make the rhexis a little larger to chop the lens into small fragments, which helps get them out easier without bringing them up into the anterior chamber. Another audience response question asked the attendees what technique they would use with a dense cataract and small pupil. About 65% indicated that they would use an expansion ring, like the Malyugin ring. The Malyugin ring has become very popular, Dr. Donaldson said. It's easy and quick to put in. There is still utility for hooks in some of these complicated cases, she added. Dr. Snyder said that physicians have to consider both rings and hooks. He is a fan of the ring but added that the hook allows the sur- geon to fixate the pupil and secure it to the limbal rim. If the capsulor- hexis margin is loose, you can use a hook to engage it more centrally and stabilize the lens, he said. Zonular management is another important topic in these difficult cases. Dr. Donaldson said that the femtosecond laser can be a good tool. She uses it because it allows for a perfect capsulotomy and prefrag- mentation of the lens for less nu- "Phacodynamics of the Rock Hard Cataract" featured tips on a number of issues associated with these challenging cases A webinar sponsored by the ASCRS Cataract Clinical Committee focused on the rock hard cataract. Gary Foster, MD, Fort Collins, Colorado, served as moderator, with Kendall Donaldson, MD, Plantation, Florida, Jonathan Solomon, MD, Bowie, Maryland, and Michael Snyder, MD, Cincinnati, as panelists. The webinar began with asking the audience which preoperative finding would put the most sweat on their brow when dealing with a rock hard cataract. Many said their biggest concerns were small pupils or loose zonules. Others were the pa- tient's ability to cooperate and dark brown coloration. Many times these all cluster to- gether and can increase complexity of the case, Dr. Donaldson said. Dr. Snyder said that the patient is the wild card. "We know what to do with these other things." Dr. Donaldson said it's import- ant to try to anticipate as many issues as possible preoperatively. A lot of these patients have had prior surgeries or vitrectomy, which can make the bag less stable, she said. Different preoperative testing can also be helpful, Dr. Snyder said. For example, if he can't see the fun- dus, he will get an ultrasound. There can be surprises, he added. Educating the patient and explaining potential complications is also important, Dr. Solomon said. When there are dense lenses, patients might still expect a 4- to 5-minute procedure and to walk out in 20 minutes, he said. You need to let patients know if you're going to be doing something beyond a tradi- tional case. The surgeons also commented on the incisions they would use in these cases. Dr. Solomon said that a large number of his cases are performed with femtosecond tech- nology. However, he does a primary incision with the blade in dense cases. Webinar focuses on rock hard cataracts Webinar reporter A dense brunescent nuclear sclerotic cataract Source: Kendall Donaldson, MD

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