Eyeworld

Reporting from ASCRS YES ACT, September 24–25, Denver EW MEETING REPORTER 164 tension ring (CTR) when needed could be helpful. When doing nuclear disassem- bly, Dr. Crandall recommended choosing a method that would mini- mize zonular stress. Jonathan Rubenstein, MD, Chicago, focused his presentation on techniques for soft, medium, and hard lenses. You have to utilize different techniques for different degrees of nuclear sclerosis (NS), he said. You cannot chop all lenses, so you need to assess the degree of NS preoperatively. Usually, the best assessment is on the first few phaco passes. Dr. Rubenstein's technique for soft lenses is called "bowl and roll." He said to do hydrodissection and delineation and to create a deep central groove on the sculpt settings. Then, he said to extend the groove peripherally to create a bowl. Dr. Rubenstein recommended using low phaco energy and then rolling the peripheral soft nucleus on quadrant settings. "As you're making that central groove, that's when you're making the decision on how soft the lens is," he said. "If it's too soft to crack, then use this technique." The technique for handling me- dium lenses was a "split and swirl." With this method, Dr. Rubenstein also uses hydrodissection and de- lineation. Then, he said to create a deep central groove with the sculpt settings and to split it into halves. Grab the edge of the hemi-nucleus on quadrant setting and swirl it into the phaco tip. Finally, for hard lenses, Dr. Rubenstein uses a stop and chop technique. He said to sculpt the deep groove and split it into halves. Then, he recommended chopping each half into fourths or eighths with a vertical chop. Further chop each segment with a horizontal chop, he said. EW Editors' note: Dr. Rubenstein has finan- cial interests with Alcon. Dr. Crandall has no financial interests related to his comments. Dr. Farid had a good size nu- cleus, the lens was in, and she was doing viscoelastic removal. However, she noticed that the wound was not closing and there was high pressure in the eye. She decided to put a su- ture in because the wound was a bit leaky. After filling the eye, however, it was still leaking. Dr. Farid noticed that after burping the wound, the iris was coming back toward her, the lens was a bit anterior and the eye was getting hard. This was a case of infusion misdirection, a variation of aqueous misdirection. All of the fluid and irrigation that she been putting into the eye had crept into the back of the eye and the pressure was high. Dr. Farid wanted to be sure that she was not encountering a suprachoroi- dal hemorrhage. Dr. Farid needed to decompress the vitreous. She used a dry vitrecto- my, and after doing a bit of vitrecto- my, she noticed that the eye col- lapsed and relaxed, and everything fell back into place and closed nicely. Editors' note: Dr. Farid has financial interests with Abbott Medical Optics, Allergan, RPS (Sarasota, Florida), Shire (Lexington, Massachusetts), and Tear- Science (Morrisville, North Carolina). Complicated cataract cases David Crandall, MD, Detroit, highlighted some important points in dealing with pseudoexfoliation. There are a number of important considerations preoperatively, he said. Dr. Crandall always checks the dilation ahead of surgery so that he will know if this could be a problem during surgery. He also said to note zonular issues, like phacodonesis, narrow angles, and asymmetric anterior chamber depth. Doing gonioscopy and taking note of the glaucoma severity are important preoperatively. "I tell every pseudo- exfoliation patient that they might need glaucoma surgery later," Dr. Crandall said. He also noted a number of intraoperative maneuvers that could be particularly helpful in these cases. Viscodissection, bimanual rotation instead of using one instrument, LEC removal, and using a capsular Derek DelMonte, MD, Denver, said if you do a lot of cataract surger- ies, one of the unplanned scenarios you're sure to encounter is vitreous. Identifying vitreous early is criti- cal. Signs can include a change in red reflex, if the lens stops rotating, a sudden change in the anteri- or chamber depth, and a sudden change in pupil size. Once vitreous in the anterior chamber is identified, Dr. DelMonte said it is important to not panic, stopping phaco but keeping both in- struments in the eye. Stay on irriga- tion, keeping the anterior chamber pressurized. A dispersive viscoelastic should be injected through the side port, and then the phaco tip can be removed. How to handle the vitreous from there depends on where it is coming from and the amount of cataract remaining in the eye. Dr. DelMonte offered several tips based on different situations. Once the vitreous is gone, Dr. DelMonte said it is your job as an anterior segment surgeon to place a lens. He also recommended use of IV acetazolamide and a steroid that will help control pressure the next day due to any viscoelastic left in the eye. "If your pressure is high the next day, never burp any wounds. Always medically manage these patients," Dr. DelMonte said. Editors' note: Drs. Davidson and DelMonte have no financial interests related to their comments. Complicated video cases Surgeons shared some of their com- plicated cataract cases in video form and discussed how they handled different complex scenarios. Marjan Farid, MD, Irvine, Cal- ifornia, described a case of infusion misdirection that she handled. Initially, the case was going well, she said. There was a good rhexis, and Dr. Farid was using a horizontal chop technique. She said it's important to go around and hug the nucleus. You want to give count- er traction with the phaco tip. You also want the nucleus centered and don't want the whole bag to move around, she added. October 2016

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