Eyeworld

99 EW FEATURE October 2016 • Challenging and complicated cataract surgery final viscoelastic so that they do not leak." She finds that this decreases the risk of collapsing the anterior chamber. When Dr. Safran treats posterior polar cataracts, he likewise modi- fies his technique to avoid hydro- dissection. "You want to gently hydrodelineate from the center avoiding aggressive distention of the capsular bag," he said, stressing that surgeons shouldn't try to cleave a plane between the cortex and the posterior capsule because that could lead to trouble if there's a preexist- ing defect there, which is present in about 20% of cases. In cases where there is a defect, the later in the case that it is revealed, the safer the sur- gery is. In other cases, where there is no congenital hole, the capsule adja- cent to the posterior capsule plaque may be somewhat weaker and more prone to breaking. "You want to leave the epinucleus or cortical shell behind so that the plaque stays with it until the very end of the case," Dr. Safran said. "After I remove the cen- tral nucleus, I remove the epinucleus and the plaque may come with it. If it does not, I leave it." After removing the central nu- cleus, if there is a sheet of epinucleus or thick cortical shell remaining, one can use a little peripheral hydrodis- section or viscodissection to sepa- rate this from the posterior capsule. "Then you peel off that last sheet and hope there's not a hole there," Dr. Safran said, adding that most of the time there isn't. "If there is, using your other hand, you try to gently inject viscoelastic and tamponade it back," he said. With a hole, a vitrec- tomy may ultimately be necessary no matter how good the technique is. To avoid rupture, in some cases the surgeon may want to leave the plaque and go back at a later time with YAG, Dr. Safran advised. The plaque is usually at the center of the lens in the back, sitting on the posterior capsule. "If you don't aggressively hydrodissect that layer, you have a good chance of preserv- ing it," he said. "If you have a soft lens, you can hydrodelineate it like an onion outward. But if it's a dense nuclear sclerotic cataract, it's tricky because there's no way you can get the hydrodelineation in those mid- dle layers, so you may try to give it a little peripheral viscodissection to help mobilize the nucleus." In cases with denser nuclei, Dr. Safran does minimal or no initial hydrodelineation or dissection. He just chops and rechops the lens, then takes a quadrant out and tries to mobilize the lens. "What you don't want to do is reveal a poste- rior capsule defect early in the case and drop the nucleus," he stressed, adding that this is why it's far better to leave the plaque in place until the end after you've removed the lens so the nucleus doesn't fall through the potential defect behind it. "Also, you want to make sure you don't aggressively distend the bag," Dr. Safran continued. Imagine putting scotch tape on a balloon; if you blow the balloon up, it is going to pop right where the scotch tape is so even if there is no preexisting defect under the plaque, there is more stress on the capsule adjacent to the plaque when it is distended. "It's important to be as gentle as possible throughout the case to avoid this type of rupture as long as plaque is present. If the plaque comes off during the case and the posterior capsule looks normal at that point, you are out of the woods, but as long as the plaque is there, the risk of a posterior capsule tear is present if it is disturbed," he said. In cases of posterior polar cata- ract, the IOL choice may be affected depending on whether or not a hole develops, Dr. Chan noted. "If the T:10.75" B:10.75" INDICATIONS AND USAGE PROLENSA ® (bromfenac ophthalmic solution) 0.07% is a nonsteroidal anti-infl ammatory drug (NSAID) indicated for the treatment of postoperative infl ammation and reduction of ocular pain in patients who have undergone cataract surgery. IMPORTANT SAFETY INFORMATION ABOUT PROLENSA ® • PROLENSA ® contains sodium sulfi te, a sulfi te that may cause allergic type reactions including anaphylactic symptoms and life-threatening or less severe asthmatic episodes in certain susceptible people. The overall prevalence of sulfi te sensitivity in the general population is unknown and probably low. Sulfi te sensitivity is seen more frequently in asthmatic than in non-asthmatic people. • All topical nonsteroidal anti-infl ammatory drugs (NSAIDs), including bromfenac, may slow or delay healing. Concomitant use of topical NSAIDs and topical steroids may increase the potential for healing problems. • There is the potential for cross-sensitivity to acetylsalicylic acid, phenylacetic acid derivatives, and other NSAIDs, including bromfenac. Use with caution in patients who have previously exhibited sensitivities to these drugs. • There have been reports that ocularly applied NSAIDs may cause increased bleeding of ocular tissues (including hyphemas) in conjunction with ocular surgery. Use with caution in patients with known bleeding tendencies or who are receiving other medications which may prolong bleeding time. • Use of topical NSAIDs may result in keratitis. Patients with evidence of corneal epithelial breakdown should immediately discontinue use of topical NSAIDs, including bromfenac, and should be closely monitored for corneal health. Patients with complicated ocular surgeries, corneal denervation, corneal epithelial defects, diabetes mellitus, ocular surface diseases (e.g., dry eye syndrome), rheumatoid arthritis, or repeat ocular surgeries within a short period of time may be at increased risk for corneal adverse events which may become sight threatening. Topical NSAIDs should be used with caution in these patients. Post-marketing experience with topical NSAIDs suggests that use more than 24 hours prior to surgery or use beyond 14 days post-surgery may increase patient risk for the occurrence and severity of corneal adverse events. • PROLENSA ® should not be instilled while wearing contact lenses. The preservative in PROLENSA ® , benzalkonium chloride, may be absorbed by soft contact lenses. Lenses may be reinserted after 10 minutes following administration of PROLENSA ® . • The most commonly reported adverse reactions in 3%-8% of patients were anterior chamber infl ammation, foreign body sensation, eye pain, photophobia, and blurred vision. Please see brief summary of full Prescribing Information for PROLENSA ® on adjacent page. References: 1. PROLENSA Prescribing Information, April 2013. 2. Data on fi le, Bausch & Lomb Incorporated. 3. Baklayan GA, Patterson HM, Song CK, Gow JA, McNamara TR. 24-hour evaluation of the ocular distribution of (14)C-labeled bromfenac following topical instillation into the eyes of New Zealand white rabbits. J Ocul Pharmacol Ther. 2008;24(4):392-398. PROLENSA is a registered trademark of Bausch & Lomb Incorporated or its affi liates. © Bausch & Lomb Incorporated. All rights reserved. Printed in USA. PRA.0188.USA.15 The PROLENSA ® Effect POWERED FOR PENETRATION Advanced Formulation to Facilitate Corneal Penetration 1-3 pH e ffect Hal og en a ti on e ffect PROLENSA ® delivers potency and corneal penetration with QD dosing at a low concentration 1-3 continued on page 100

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