Eyeworld

EW CATARACT 46 September 2016 by Liz Hillman EyeWorld Staff Writer to pull outwardly at 360 degrees to support that central mesh of the trampoline, which is basically what the cataract is," Dr. Kim said. "If those zonules are not pulling outwardly at 360 degrees, as you can imagine, the trampoline mesh will start to sag." Other signs of zonulopathy in- clude a capsulorhexis that does not puncture or grab easily. "It's like trying to catch an apple [in water] with Vaseline on your fin- gers," Dr. Kim said, describing how the anterior capsule will bob up and down as you try to grab it when the zonules have no counterforce. If you are able to grab the capsulorhexis, you might see folds forming as you pull it. Another sign of zonulopathy is having trouble rotating the lens inside the bag, Dr. Kim said. Dr. Zavodni said when zonular instability is identified, capsular retraction hooks should be placed as early as possible to decrease the risk for zonular dialysis. He also noted that, if possible, he would recom- mend using a peristaltic machine with these cases as the disassociation of aspiration and vacuum improves overall control during lens disassem- bly and removal. In an effort to gain optimum control, Dr. Zavodni ad- vised lowering the flow rate during quadrant removal, which he said "is most important during removal of the final nuclear piece as weak zonules have a tendency to have floppy posterior capsules that are more likely to come forward follow- ing nucleus removal than normal eyes. Rather than changing fluidic settings on the fly, the surgeon may elect to use the preset epinuclear mode during the removal of the last piece of the nucleus, as this setting typically has a programmed drop in both flow rate and vacuum." Dr. Zavodni also said that a surgeon encountering weak zonules should be well versed in capsular tension ring (CTR) placement. He added that while a CTR can help with bag centration, it does not prevent aggressive capsular phimosis contraction. happening before you proceed," Dr. Kim said. Settings and techniques for zonular weakness were among the many topics discussed in a recent ASCRS webinar "PhacoFun: Ex- pecting the unexpected," which was sponsored by the Young Eye Surgeons (YES) Clinical Committee and featured host Berdine Burger, MD, Carolina Eyecare Physicians, Charleston, South Carolina, along with panelists David F. Chang, MD, clinical professor, University of California, San Francisco, Zachary Zavodni, MD, The Eye Institute of Utah, Salt Lake City, and Dr. Kim. Zonulopathy In the case of zonular instability or weakness, the first step is to identify the signs. Those, Dr. Kim said, could be seeing the lens push back and the chamber deepening considerably as you put in viscoelastic. "The zonules are like springs of a trampoline, and they're supposed What to do in cases of weak zonules, anterior capsule tear O ptimizing phaco machine parameters for standard cataract surgery is im- portant for the young eye surgeon to master, but knowing how to adjust settings and techniques for complicated situa- tions can be even more crucial. "The most important thing, when you're talking about complica- tion management, that a young eye surgeon needs to do is first recognize what is going on," said D. Brian Kim, MD, Professional Eye Associ- ates, Dalton, Georgia. "When you start to see things going sideways, you don't just pray everything is OK and keep chugging along. "Stop, keep irrigation going, put some viscoelastic in the eye, take the phaco tip out, and use some instruments to help reassess what is Expecting the unexpected: Settings and techniques for complicated cataract cases T he Young Eye Surgeons (YES) Clinical Committee sponsors several free webinars a year. These webinars have been focusing on phacodynamics and have been well attended. Interestingly, the audience has been broad, with a large por- tion being ophthalmologists who have been in practice for many years. This proves that all of us can benefit from reviewing these essential fundamentals. The webinars—along with numerous other valuable resources—are available at ASCRS' Center for Learning (ascrs.org/ center-for-learning). Most of the time, our standard settings for the phacoemulsifi- cation machine are appropriate. However, we have to adjust for difficult situations, and it is obviously better to know how to react by preparing in advance than to try to figure things out on the fly in a stressful OR setting. In this month's "YES Connect" column, the panelists from the most recent webinar share their insights on how to identify and handle zonular problems, dense cataracts, and anterior capsular tears. Just as they did in May of this year, D. Brian Kim, MD, and David F. Chang, MD, joined two YES Clinical Committee members, Berdine Burger, MD, and Zachary Zavodni, MD, to share their thoughts in EyeWorld. Bryan Lee, MD, YES Connect co-editor During creation of the capsulorhexis, Dr. Chang pointed out how the dyed capsule moved in this rock hard cataract pseudoexfoliation case, noting it as evidence of weak zonules. continued on page 48 YES Connect

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